Brett Kay, NCQA Susan Radke, CMS Sandra Jones, NCQA

Brett Kay, NCQA Susan Radke, CMS Sandra Jones, NCQA
SNP Approval Model of Care Training Elements January 21, :00 – 4:00PM EST Brett Kay, NCQA Susan Radke, CMS Sandra Jones, NCQA SNP 1 through 3 Training

Objectives of SNP MOC Scoring Guidelines
Revise structure of the MOC to help plans better understand and meet the requirements Model after S&P measures format Approach familiar to the SNPs SNPs have publicly requested such a change Supports consistent scoring of MOCs As you just heard, CMS has revised the Model of Care Guidelines. In order to provide a way to assess and score the new guidelines, NCQA worked with CMS to create a revised format to the scoring criteria. The goal of the revised scoring criteria is to make the requirements more transparent and objective, both for SNPs developing a Model of Care and for NCQA reviewing them. In order to do this, we revised them using NCQA’s Standards/Structure & Process measures approach. For those of you familiar with NCQA Accreditation and the SNP S&P measures assessment, this new format should look familiar. SNP 1 through 3 Training

MOC Scoring Guidelines
Used revised Appendix 1 of the MA application Model of Care Upload document—kept requirements intact, but revised formatting Received input from stakeholders: Public Comment process 222 comments Health plans, trade associations, provider groups, others We had strict parameters that we needed to follow, so you will see that the language in the scoring criteria hew very closely with the language in the revised Model of Care guidelines. We revised the formatting to fit within the NCQA S&P measures structure, but the actual requirements and intent are consistent with the MOC guidelines. CMS issued a public comment process over the summer, where stakeholders had an opportunity to comment on the requirements. CMS addressed those comments and finalized the guidelines based on that input. NCQA drafted our scoring criteria based on CMS’ position. We then held our own public comment in the fall to solicit comments. We received many comments, some of which echoed comments provided to CMS in the summer.

How will NCQA Score the MOC?
Scoring will be similar to previous years MOC elements worth 0-4 points, based on # of factors met. Total of 60 points (15 elements) converted to percentage scores E.g., 50 points = 83.33% (2-year approval)

Previous MOC Scoring Guidelines New MOC Scoring Guidelines
Element Maximum Score MOC 1: SNP-specific Population 4 MOC 2: Measurable Goals 12 MOC 3: staff Structure/roles MOC 4: ICT MOC 5: Provider Network 20 MOC 6: MOC Training 16 MOC 7: HRA MOC 8: ICP MOC 9: Communication Network MOC 10: Vulnerable Populations 8 MOC 11: Outcome Measurement 24 Total 160 New MOC Scoring Guidelines Element Maximum Score MOC 1: SNP Population 8 MOC 2: Care Coordination 20 MOC 3: Provider Network 12 MOC 4: Quality Measurement Total 60

Crosswalk to New Elements
MOC 1: SNP Population MOC 2: Care Coordination Care Transitions Protocol NEW! MOC 3: Provider Network MOC 4: Quality Measurement Old Elements MOC 1: SNP-specific Population MOC 10: Vulnerable Populations MOC 3: Staff Structure/Care Management Roles MOC 4: Interdisciplinary Care Team MOC 7: Health Risk Assessment MOC 8: Individual Care Plan MOC 9: Communication Network MOC 5: Provider Network & Use of Clinical Practice Guidelines MOC 6: MOC Training MOC 2: Measurable Goals MOC 11: Outcome Measurement

Project Time Line February 25 – MA/SNP & Medicare-Medicaid Plans (MMP) Applications submitted to CMS via HPMS March 11 –MMP application results to CMS MA/SNP reviews continue March 17 – CMS issues Deficiency Notices to MMPs -- Begin “Cure Process” - Plans have 7-10 calendar days to submit additional information March 18 MMP Cure 1 TA call for Plans scoring <70%

Project Time Line March 24 Cure 1 MMP Apps due to CMS
April 28 – CMS issues Notice of Intent to Deny April 30 – MA/SNPs & MMP TA call for Plans scoring <70% May 8 - MA/SNP & MMP Cure Apps due May 28 – CMS issues MA/SNP Denial Notices & MMP Status Notices June 2 - SNP bids due to CMS

MOC 1: Description of SNP Population
Sandra Jones

MOC 1: Description of SNP Population
Intent: Identify and describe the target population, including health and social factors, and unique characteristics of each SNP type Focus is on a description that: Provides a foundation upon which the remaining measures build a complete continuum of care (e.g. end-of-life & special considerations) for current and potential members the plan intends to serve. Includes specially tailored services for members considered “most vulnerable” (e.g. multiple hospital admissions or excessive spending on medications above set limits) The intent of MOC 1 is for a Plan to identify and describe its target population, including health & social factors, and unique characteristics of each SNP type e.g. Dual, Chronic and/or Institutional. For MOC 1, we are looking for plans to build a foundation upon which the remaining elements continue to frame the MOC narrative by specifically addressing how it cares for its members or in the case of a new or expanding plan, how it intends to address care needs. Again, the emphasis is on designing a full continuum of care to address current and any potential issues members may experience through end of life needs & considerations. NCQA recognizes that the Matirx Upload document and the scoring guidelines differ slightly in their structure for MOC 1. We split up the requirements into 2 elements to place emphasis on each requirement in the Upload document and to facilitate scoring. Please note that the requirements align between both documents, but the numbering is different. With regard to Element B, when you discuss those members considered “especially vulnerable” , use specific terms to define the population e.g. certain diagnosis, members with multiple admissions within a specified timeframe or medications costs exceed certain limits.

MOC 1 Element A: Overall SNP Population
Factor 1 MOC Description: Emphasis is on process* and relevant resources used, not care coordination: Member identification Verification of eligibility Tracking *Process includes information on systems or data collection methodology used to identify and track eligible beneficiaries Now let’s talk about what each factor in Element A “Overall SNP Population” requires: Factor 1: The emphasis is on the description of your plan’s process, not the provision of care. We are looking for the process staff use to identify, members, and to verify and track to ensure eligibility thus avoiding interruption in care and services. Plans should include resources such as systems and data collection methodology used for this purpose.

Factor 2 Separated social and medical/health factors; the focus is on social, cognitive and environmental factors*. MOC description must also include Social & environmental factors; living conditions Cultural or linguistic challenges Barriers to health care delivery Caregiver concerns *Potential factors that may interfere with provision of health care or services, caregiver considerations or other concerns. Factor 2: We separated the social and medical health factors. In factor 2, the focus is on the social, cognitive and environmental issues for the targeted population. We will address medical & health issues in factor 3. First, the narrative must include a description of the population your plan serves or intends to serve. The takeaway for this factor is how you define your population and the associated social, cognitive and environmental factors that may impact it. We need you to get specific about the characteristics of the target population such as average age, gender & ethnicity, incidence and prevalence of major diseases, presence of chronic diseases. The use of statistics gathered from state or county resources is appropriate; however, use of overall data derived from national statistics will not meet the requirement.

Factor 3 Focus is on medical/health/cognitive factors* MOC description must also include Current health status of members Associated behavioral health issues Co-morbidities *Disease characteristics that could impact present status Factor 3: In factor 3 the focus is on the medical and health issues of the targeted population. Describe the current health status of members as well as any co-morbidities, incidence and prevalence, and behavioral health issues. As in factor 2, the use of statistics gathered from state, county or regional resources is appropriate; however, use of overall data derived from national statistics will not meet the requirement. I can’t emphasize this point enough. Many plans score low in this area because the description does not address the plan’s targeted population with specificity.

Factor 4 Characteristics of population per SNP type Includes limitations & barriers that affect overall health C- SNP – chronic conditions, incidence & prevalence D-SNP – Full/partial; including limitations & barriers I-SNP –Facility type; specialty providers & services; limitations & barriers In factor 4, the focus is on SNP type and the limitations, barriers and challenges affecting each. For C- SNPs, what are the chronic conditions, incidence & disease prevalence associated with your SNP? Talk about the co-morbidities and potential problems with coordination of care especially multiple providers. With D-SNPs, describe your dual memberships. Is it full/partial; again, include limitations, barriers & challenges faced by this population type. Specifically, how do you handle or plan to handle coordination of Medicare & Medicaid benefits and poor health literacy? When describing your I-SNP, specify the facility type where members reside; is it facility, home or community based (e.g. institutional equivalent)? What kind of specialty providers & services does this population require? Last but certain equally significant, what limitations & barriers pose challenges (e.g. dementia, frailty, lack of family/ caregiver resources/support).

MOC 1B: Most Vulnerable Beneficiaries
Intent: Describe the most vulnerable beneficiaries and how their medical/social factors affect health outcomes and what services/resources the SNP provides to address these Focus: Important to note that the focus is on population-level, not individual members Simply put, what makes them “different”? Please note that there is where the scoring guidelines are slightly different from the Matrix Upload format as previously discussed. Although the definition of “SNP beneficiary” typically implies members requiring additional care and services, the description focuses on the sickest or most vulnerable SNP members.

MOC 1 Element B: Most Vulnerable Beneficiaries
Factor 1 Plan definition of “most vulnerable” and includes: Robust & comprehensive description of members Methodology used for identification (e.g. specify data collected from various resources, multiple admits/readmits, high pharmacy utilization, high risk stratification, specific diagnosis & subsequent treatment required) Medical, psychosocial, cognitive or functional challenges Any specially tailored services geared towards this population For factor 1, while the definition of a SNP implies that members require additional care or services, what is your plan’s definition of “most vulnerable population”? How do you identify these beneficiaries? These two components are integral to your definition. Specify: What sets them apart from the overall SNP population Describe the methodology used for identification; this goes back to your data collection resources Specially tailored services for which members are eligible The organization may use beneficiary information from other product lines (e.g., Medicare Advantage or Medicaid plans) as an example of the intended target population if the plan does not have members, or it must provide details compiled from the intended plan service area.

MOC includes a description of the most vulnerable members specifically: Factor 2 Explain how certain characteristics (e.g. average age, gender, ethnicity, language barriers, etc.) affect health outcomes of the “most vulnerable”: Demographic characteristics (e.g. average age, gender, ethnicity, language barriers, health literacy, socioeconomic status Factor 3 Draw a correlation between demographic characteristics and clinical requirements: Specify how the characteristics adversely affect health status & outcomes and the need for unique clinical intervention There is a relationship between factors 2 & 3. The organization’s MOC definition of its most vulnerable beneficiaries must describe the demographic characteristics of this population (i.e., average age, gender, ethnicity, language barriers, deficits in health literacy, poor socioeconomic status and other factors) and specify how these characteristics combine to adversely affect health status and outcomes and affect the need for unique clinical interventions. The definition must include a description of special services and resources the organization anticipates for provision of care to this vulnerable population.

Factor 4 Establish relationships with community partners Describe the process for partnering with community providers to deliver needed services: Type of specialized resources and services How the Plan facilitates member/caregiver access Guarantee provision of continuity of eligible services For factor 4, the organization’s MOC must describe its process for partnering with providers within the community to deliver needed services to its most vulnerable members, including the type of specialized resources and services provided and how the organization works with its partners to facilitate member or caregiver access and maintain continuity of services.

QUESTIONS

MOC 2: Care Coordination
Brett Kay Now, we are going to move to MOC 2, which addresses care coordination.

MOC 2: Element A: SNP Staff Structure
Intent: Describe admin/clinical staff roles and responsibilities Focus: How care coordination (e.g. health care needs, preferences and sharing information across health care staff and facilities) occurs All elements must address the SNP’s care coordination activities in detail Element A addresses the staff structure including administrative and clinical roles and responsibilities and how the staff works provide high quality care for its members.

Factor 1: Describe the administrative staff roles, responsibilities, and oversight functions. Identify & describe employed or contracted staff that perform administrative functions: Enrollment and eligibility verification Claims processing Administrative oversight For factor 1, the organization’s MOC defines staff roles and responsibilities across all health plan functions for personnel that directly or indirectly affect the care coordination of SNP beneficiaries. The organization’s MOC must identify and describe the specific employed and contracted staff responsible for performing administrative functions, including: Enrollment and eligibility verification. Claims processing. Administrative oversight.

Factor 2: Describe the clinical staff roles, responsibilities and oversight functions Identify & describe employed or contracted staff that perform clinical functions including: Directing beneficiary care & education Care coordination Pharmacy consultation Behavioral health counseling Clinical oversight (e.g., describe how license/competency verification relates to specific population being served) The organization must identify and describe the employed and contracted staff that perform clinical functions, including: Direct beneficiary care and education on self-management techniques. Care coordination. Pharmacy consultation. Behavioral health counseling. Clinical oversight. Staff oversight responsibilities must include any license and competency verification that relates to the specific population being served by the organization (e.g., geriatric training for I-SNP providers or special training for physicians and other clinical staff for a C-SNP services beneficiaries with HIV/AIDs; data analyses for utilization of appropriate and timely health care services; utilization review; and provider oversight to ensure use of appropriate clinical practice guidelines and integration of care transition protocols.

Factor 3: Coordination of responsibilities and job title Describe how identified staff responsibilities coordinate with job title e.g. impact of staff changes: Title or position Levels of accountability To show how staff responsibilities identified in the MOC are coordinated with job title for factor 3, the organization must provide a copy of its organization chart and, if applicable, a description of instances when a change to staff title/position or level of accountability is required to accommodate operational changes in the SNP. Plans should describe instances when changes in staff responsibilities may occur. Does the level of accountability change say for contacted staff or in the case of a new hire?

Factor 4: Contingency plan Identify & describe contingency plans to ensure continuity of staff functions. Factor 5: Initial & annual MOC training Describe the process for conducting initial & annual MOC training Training content & strategies Employed & contracted staff* *Contracted staff do not include physicians or other providers Factor 4 requires the SNP to have a contingency plan in place to avoid disruptions in the provision of care and services. The contingency plan addresses what the expectations are in the event of staff who can no longer perform their roles and responsibilities. Plans may have different contingency plans for different circumstances—e.g., natural disasters or staff departures. For factor 5, The organization must conduct initial and annual MOC training for its employed and contracted staff. The MOC must describe the training strategies and content. The description must include types of trainings and specific examples of slides or training materials. If the training plan is not currently operational, the organization’s MOC must provide a description of the plan’s contents. Contracted staff do not include physicians or other providers that the organization contracts with as part of the provider network. Please note that this does not apply to contracted providers, as that will be addressed in MOC 3, which we will cover on Thursday, Jan. 23.

Factor 6: Maintaining training records Describe how the plans documents & maintains training records: Process for documenting completion of required training; and How/where the Plan maintains training records For factor 6, the plan must describe the methodology it uses to document and maintain training records as evidence that staff have completed MOC training. This must include how and where the records are maintained, e.g., training logs, database. What we are looking for is the description of how the plan knows that all of its staff are properly trained.

Factor 7: Corrective actions: Describe the actions taken if staff do not complete required MOC training Explain challenges to completing training for employed and contracted staff Actions taken for missed or deficient training Factor 7 requires the plan to explain challenges associated with employed and contracted staff completing training and must describe actions the organization will take when the required MOC training has not been completed or has been found to be deficient. In other words, if staff have not receive the proper training, what actions will the plan take to make sure they do receive the training.

MOC 2: Element B: Health Risk Assessment Tool
Intent: Describe how the HRAT collects and uses data to assess medical, functional, cognitive, psychosocial and mental health needs of members. Focus: How the HRAT is used to develop the ICP Dissemination of information to ICT Process for conducting the initial and annual assessments Methodology used to review, analyze and stratify HRA results This element requires plans to provide a description of the HRAT, specifically how it is used in the coordination of members care e.g. the development and updating of the ICP and how it communicates the results to the ICT. The description also includes the process for conducting the initial and annual assessments, the rationale for reviewing, analyzing and stratifying HRAT results and communicating that information to member/caregiver & stakeholders.

Factor 1: Describe the use and dissemination of HRAT information: Describe the data collected: Medical Functional Cognitive Psychosocial; and mental health needs of members Process for developing and updating the ICP in a timely basis For factor 1, plans must provide a description of the HRAT content. specifically the data collected and the process used to develop and update the ICP.

Factor 2: Disseminating HRAT information Describe the process for sharing HRAT information with the ICT ICT use of HRAT information Integration of results into the ICP Factor 3: Initial HRA & annual reassessment Describe the process including: Timeframe for conducting (e.g. initial & annual) Methodology (mailed, in-person, phone interview) Contacting members not responding to mailings or calls For factor 2, plans must provide detail on how it disseminates the results of HRAT data collected to the ICT and how the ICT uses that information. Factor 3, the MOC narrative describes when and how the initial HRA and annual reassessment occurs. Specifically, the timeframe for each, the methodology the plan uses (is the assessment mailed” What is the process? Is the interview conducted by phone or in person? By whom? ) The organization must complete the HRAT for each beneficiary, for initial assessment, and must complete an HRAT annually thereafter. At minimum, the organization must conduct initial assessment within 90 days of enrollment and must conduct annual reassessment within one year of the initial assessment. The description must include the methodology used to coordinate the initial and annual HRAT for each beneficiary and the timing of the assessments. There must be a provision to reassess beneficiaries, if warranted by a health status change or care transition (e.g., hospitalization, change in medication, multiple falls). The organization must describe its process for attempting to contact beneficiaries and have them complete the HRAT, including provisions for beneficiaries that cannot or do not want to be contacted or complete the HRAT.

Factor 4: Plan & rationale Describe the process used to review, analyze and stratify HRAT results Detail stratification process Communication of stratification results: ICT Provider network (e.g. specialty providers, allied or behavioral health practitioners) Members/caregivers; other SNP personnel as applicable Explain how the SNP uses results to improve care coordination The organization’s MOC must describe its plan and explain its rationale for reviewing, analyzing and stratifying HRAT results. It must include the mechanisms for communicating information to the ICT, provider network, beneficiaries and/or their caregivers and other SNP personnel who may be involved with overseeing a beneficiary’s plan of care. If the organization uses stratified results, the MOC must explain how the SNP uses the results to improve the care coordination process.

MOC 2: Element C: Individualized Care Plan (ICP)
Intent: Describe how the ICP is developed and communicated Focus Describing the essential elements of the ICP Detail the process for development/modification Identify staff responsible How updates to the ICP are: Documented Maintained; and Communicated. The intent of Element C is to describe how the SNP develops/updates the ICP. Focus: Clarify that CMS expects an ICP for all SNP beneficiaries but allows flexibility for the SNP to determine level of detail for ICPs—may stratify by risk and place priority on high risk/high need beneficiaries Factor 1: Description must address the essential components of ICP Factors 2 & 3: Process for developing & staff responsible for maintaining; including their role & functions Factor 4: Describes the process for documenting, updating and modifying the ICP; and Factor 5: Addresses the process for communicating those updates and modifications

Factor 1: ICP essential components Description includes: Member’s self management goals & objectives Personal health care preferences Services specifically tailored to beneficiary’s needs The organization must develop an ICP for each beneficiary, to deliver appropriate care to the beneficiary. The organization’s ICP must include, but is not limited to: The beneficiary’s self-management goals and objectives. The beneficiary’s personal healthcare preferences. A description of services specifically tailored to the beneficiary’s needs. Identification of goals (met or not met). If the beneficiary’s goals are not met, the organization’s MOC must describe the process for reassessing the current ICP and determining the appropriate alternative actions.

Description includes: Factor 2: ICP development process & staff responsible Process for ICP development Details staff responsible e.g. role & functions, professional requirements and credentials Factor 3 Personnel responsible for development of ICP, including involvement of member/caregiver Factors 2 & 3: ICP development process and personnel The organization’s MOC must describe the process for developing the ICP and must detail the personnel responsible for developing the ICP. The description of responsible staff must include roles and functions, professional requirements and credentials necessary to perform these tasks, as well as how the beneficiary or their caregiver/ representative is involved in the ICP development. The MOC must also include a description of how the organization determines how often to review and modify, as appropriate, the ICP as the beneficiary’s health care needs change.

Factor 4 Process for determining the frequency for review & modification when changes occur Factor 5 Communication of updates and modifications to the ICP Factor 4: ICP documentation and maintenance The organization’s MOC must describe how the ICP is documented and updated and where the documentation is maintained so it is accessible to the ICT, provider network and beneficiaries and/or their caregivers. Factor 5: Updates and modifications The organization’s MOC must describe how the organization communicates ICP updates and modifications to beneficiaries and/or their caregivers, the ICT, applicable network providers, other SNP personnel and other stakeholders, as necessary.

MOC 2: Element D: Interdisciplinary Care Team (ICT)
Intent: Describe the key components of the ICT Focus: Key members of ICT Roles/responsibilities How the ICT contributes to improving beneficiary health status Communications within the ICT The intent of element D is to describe the key components of the ICT Factor 1: Identifies key members of the ICT Factor 2: describes member roles & responsibilities Factor 3: explains how the ICT contributes to improving overall beneficiary health status; and Factor 4: describes the SNP’s communication plan e.g. how it occurs among group members. We also want to clarify that the ICT may meet “virtually” using various forms of communication/technology (face-to-face is not required)

Factor 1: ICT membership Description includes: How the SNP determines key members of ICT e.g. specialized expertise requirements Process for facilitating participation of beneficiary/caregiver Use of member HRAT results & ICP to identify ICT membership Explain how ICT uses health care outcomes to evaluate established processes The organization’s MOC must describe the composition of the ICT, including how the SNP determines ICT membership and the roles and responsibilities of each member. The description must specify how the expertise and capabilities of the ICT members align with the identified clinical and social needs of the SNP beneficiaries. The organization must: Explain how the SNP facilitates the participation of beneficiaries and their caregivers as members of the ICT. Describe how the beneficiary’s HRAT and ICP are used to determine the composition of the ICT; including where additional team members are needed to meet the unique needs of a beneficiary. Explain how the ICT uses health care outcomes to evaluate processes established to manage changes or adjustments to the beneficiary’s health care needs on a continuous basis.

Factors 2 & 3: ICT Roles & responsibilities Description includes: Use of clinical managers, case managers & others to provide interdisciplinary care How the SNP includes member/caregiver in the process Provision of needed resources How the SNP facilitates member/caregiver access to ICT members Factors 2 & 3: The description details how the ICT roles & responsibilities contribute to the development and implementation of an effective ICT process. In other words, how the SNP uses its clinical practitioners, care managers or other providers to create an effective plan of care e.g. It also describes how the SNP includes the member/caregiver in the process and ensures the member/caregiver has access to ICT members.

Factor 4: Communication plan Description includes: Evidence of an established communication plan Process for maintaining effective and ongoing communication Verification of communication e.g. ICT meeting minutes, ICP documentation Communication with members identified with challenges e.g. hearing impairments, language barriers or cognitive deficiencies Factor 4: asks the SNP to describe its communication plan The MOC must describe the SNP’s communication plan for promoting regular exchange of beneficiary information within the ICT. The MOC must show: Clear evidence of an established communication plan that is overseen by SNP personnel who are knowledgeable and connected to multiple facets of the SNP MOC. How the SNP maintains effective and ongoing communication among SNP personnel, the ICT, beneficiaries and/or their caregivers, community organizations and other stakeholders. The types of evidence used to verify that communications have taken place (e.g., written ICT meeting minutes, documentation in the ICP). How communication is conducted with beneficiaries who have hearing impairments, language barriers and cognitive deficiencies.

MOC 2: Element E: Care Transition Protocols
Intent: Describe the SNP’s processes to coordinate care transitions and facilitate timely communications across settings and providers. Focus: Factor 1: The process for coordinating transitions Factor 2: Personnel responsible for coordination efforts Factor 3: Description of coordination between settings during a care transition Factor 4: How beneficiaries have access to personal health information to facilitate communication with providers Factor 5: Education provided to members/caregivers to manage conditions and avoid transitions Factor 6: Process used to notify members/caregivers of staff assigned to support member through transitions This is a new element to the MOC guidelines, the intent is to address transitions of care and personnel responsible for coordinating those transitions. Specifically: Factor 1: the process for coordinating transitions Factor 2 Personnel responsible for coordination efforts Factor 3: Description of the steps staff managing transitions take before, during & after transitions Factor 4: description of how beneficiaries have access to their health information so they can communicate effectively with providers in other health care settings that may not be directly affiliated with the SNP or the members’ ICT. Factor 5:Education provided to members/caregivers to manage conditions and avoid transitions Factor6: Process used to notify members/caregivers of staff assigned to support member through transitions

Factor 1: Process for coordinating transitions The description must specify: Process & rationale used to connect members with appropriate providers Factor 2: Personnel responsible for coordination efforts Identify & describe staff responsible for: Coordinating care transition process Ensuring follow-up services e.g. scheduling appointments, needed resources Factor 1: the process for coordinating transitions for example, how is a transition identified? What steps are taken? Factor 2 What personnel are responsible for coordination efforts? Case manager? Provider? Does the responsibility change per SNP type e.g. I-SNPs or community- based SNPs?

Factor 3: Applicable transitions Description of the steps staff managing transitions take before, during & after transitions Factor 4: Access to health information Process for facilitating member/caregiver access to health information necessary to communicate with providers in other healthcare settings or outside the network. Factor 3. The organization must ensure that elements of the beneficiary’s ICP are transferred between health care settings when the beneficiary experiences a transition in care. The MOC must describe the steps that take place before, during and after a transition in care has occurred for this process. Factor 4: Beneficiary personnel health information The organization must describe the process for ensuring that SNP beneficiaries and/or their caregivers have access to and can adequately use personal health information to coordinate care for the beneficiary.

Factor 5: Self-management activities Education provided to members/caregivers to manage conditions and avoid transitions Signs & symptoms of worsening condition How to respond to changes Factor 6: Notification of point of contact Process used to notify members/caregivers of staff assigned to support member through transitions Factor 5:Education provided to members/caregivers to manage conditions and avoid transitions. The MOC must describe how beneficiaries and/or their caregivers will be educated about their condition, how they will demonstrate understanding of changes in their condition (improvement, stable or worsening), and use of appropriate self-management activities. For example, they should be educated about signs and symptoms signaling a change in their condition and how to respond to such changes. Self-management activities can include regular assessment of progress, goal setting and problem solving support to reduce crises and improve health outcomes. Factor6: The organization must describe the process it uses to notify beneficiaries and/or their caregivers of the personnel responsible for supporting them through transitions between any two care settings. Simply put, how does the member or his caregiver know which staff serves as the person responsible for addressing their issues, questions or concerns?

Training & Education Sessions focus on MOC Requirements & Technical Assistance -- MOC Elements 1 & 2 (1 training) January 21* 2:00-4:00pm ET -- MOC Elements 3 & 4 (1 training) January 23* 2:00-4:00pm ET -- Technical Assistance Calls 2:00 – 3:30 pm ET February 11 March 18 for MMP scored <70% April 30 MA/SNPs & MMPs scored <70% * Recordings and slides available on NCQA SNP Approval website within one week of call

CMS Contacts For technical inquires related to the MOC program plan requirements, appeals/denials or other issues related to the SNP/MMP approval proposal in the regulations, please contact CMS at: CMS SNP mailbox Subject line: SNP MOC Inquiry CMS MMP mailbox Subject line: MMP MOC Inquiry NCQA SNP Approval Website for training recordings and slides:

QUESTIONS

Brett Kay, NCQA Susan Radke, CMS Sandra Jones, NCQA

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