SNP Approval Model of Care Training Elements 1-2 January 21 ...
SNP Approval Model of Care Training Elements 1-2 January 12, 2016 3:00 4:30pm EST Brett Kay, NCQA, Susan Radke, CMS, Sandra Jones, NCQA and Nidhi Dalwadi Mehta, NCQA Objectives of Special Needs (SNP) Model of Care Review Comply with statutory requirements of Affordable Care Act Ensure SNPs have robust Models of Care Establish frequency for approval review cycle (1-3 years) SNP Approval MOC Training, Elements 1-2 January, 2016
2 MOC Elements MOC 1: SNP Population MOC 2: Care Coordination Care Transitions Protocol MOC 3: Provider Network MOC 4: Quality Measurement SNP Approval MOC Training, Elements 1-2 January, 2016 3 How will NCQA Score the MOC? 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) 85%+ --3-year approval 75-84%--2-year approval 70-74%--1-year approval. Plans scoring <70% after the initial review will have one Cure process. Plans that undergo the Cure, will only receive a 1-year approval, regardless of their final score. SNP Approval MOC Training, Elements 1-2 January, 2016 4 Project Time Line
February 9 Technical Assistance call prior to submission February 17 SNP and MMP applications submitted to CMS via HPMS April 18 CMS issues Notice of Intent to Deny April 21 TA call for Plans scoring <70% April 28 - Cure apps due in HPMS May 25 CMS issues Denial Notices June 6 - Bids due to CMS SNP Approval MOC Training, Elements 1-2 January, 2016 5 Updates for this Review Period Discontinuing Dual Eligible Special Needs Plans Sub-type Categories
Current D-SNPs under a MA-PD contract do not have to submit separate applications or MOC narratives to offer a different subtype category type. Current SNPs under a MA-PD contract do not have to submit a MOC for a Service Area Expansion SNP Approval MOC Training, Elements 1-2 January, 2016 6 Keep in Mind SNPs and MMPs must identify all H-numbers that fall under the same MOC on the Matrix Upload document While the MOC is the same we want to see specificity on the target population at the local service area (PBP) level, not the national level.
Data and analysis must be relevant to specific populations in each service area Expectation is for SNPs to submit a new MOC each renewal period with process updates and changes (e.g., changes to goals as a result of analysis of outcomes or process improvements), and not the same MOC previously approved MOC will receive a new score Target population description is not your overall/national population SNP Approval MOC Training, Elements 1-2 January, 2016 7 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) SNP Approval MOC Training, Elements 1-2 January, 2016
9 MOC 1, Element A: Overall SNP Population 1. Describe how the health plan staff will determine, verify and track eligibility of SNP beneficiaries. 2. Describe the social, cognitive and environmental factors, living conditions and co-morbidities associated with the SNP population. 3. Identify and describe the medical and health conditions impacting SNP beneficiaries. 4. Define the unique characteristics of the SNP SNP Approval MOC Training, Elements 1-2 January, 2016 population served.
10 MOC 1, Element A Example- factor 1 D-SNP example: The plan receives enrollment applications directly from beneficiaries via the sales agent. The enrollment data analyst reviews the application and checks eligibility via the Medicaid state system. Beneficiaries who are not identified in the Medicaid system as having a qualifying category of eligibility are pended for 21 days or until the end of the month (whichever is later) at which time the enrollment data analyst reviews the state Medicaid system to confirm eligibility before processing the members enrollment request or denying the enrollment request. On a monthly basis, all SNP members Medicaid eligibility is verified with the state Medicaid agency. Members identified as not meeting the SNP eligibility requirements are notified and are given a grace period of 90 days, starting the first of the following month, to regain Medicaid eligibility or they will be disenrolled from the SNP plan. Prior to disenrollment, the enrollment data
analyst reviews each member identified as losing their Medicaid eligibility by querying the state Medicaid system. The member will either be disenrolled for loss of SNP eligibility or take the necessary action for reinstatement. SNP Approval MOC Training, Elements 1-2 January, 2016 11 MOC 1, Element A Example- factor 3 Our C-SNP (Diabetes Mellitus) notes: 20% of the population is diagnosed with DM. While CVD, CHF and decreased kidney function diagnoses are often correlated, members with these conditions also tend to have comorbidities including neurological disorders (2%), musculoskeletal disease (2%), pulmonary disease (5%), kidney disease (30%) and psychiatric disorders (25%).
SNP Approval MOC Training, Elements 1-2 January, 2016 12 MOC 1, Element B: 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 factors Focus: - Important to note that the focus is on population-level, not individual members - Simply put, what makes them different from the general population?
SNP Approval MOC Training, Elements 1-2 January, 2016 13 MOC 1, Element B: Most Vulnerable Beneficiaries Contd. 1. Defines and identifies the most vulnerable beneficiaries within the SNP population and provides a complete description of specially tailored services for such beneficiaries. 2. Explains how the average age, gender, ethnicity, language barriers, deficits in health literacy, poor socioeconomic status, as well as other factors, affect the health outcomes of the most vulnerable beneficiaries. 3. Illustrates a correlation between the demographic
characteristics of the most vulnerable beneficiaries and their unique clinical requirements. 4. Identifies and describes established relationships with partners in the community to provide needed resources. SNP Approval MOC Training, Elements 1-2 January, 2016 14 MOC 1, Element B Example- factor 2 Our most vulnerable members have multiple chronic and complex medical and behavioral conditions which may lead to multiple hospital re-admissions or complex medication regimens and may experience functional, social, and environmental issues that limit their access to medical services. As this is a service area expansion, we expect to see some common characteristics noted in our plans in surrounding
counties e.g., sensory or communication issues such as language, hearing or cognitive difficulties, disability and related issues that impact access to health care services or create specific health challenges such as minimal physical activities, lack of appropriate transportation or impaired mobility, which may increase fall risks. These members may also experience caregiver issues including loss of a caregiver, vulnerability to abuse or neglect and an unstable home environment, low Approval MOC Training, Elements 1-2 January, 2016 literacy levels resulting in difficultySNP understanding health issues 15
MOC 1, Element B Example- factor 4 SmartHealth has the following resources available to support and assist SNP beneficiaries with clinical, behavioral/mental health, social, environmental/housing, financial and other personal health and supportive needs. Cell Phone Programs Free or discounted cellular service for income eligible consumers Adult Protective Services /Elder Abuse to obtain specific Local Department of Social Services APS Mobile Crisis Service Center Services for people experiencing or a risk or a psychological crisis who requires mental health intervention, information and
referrals, linkage to appropriated treatment Caregiver Relief Services South Carolina Office of Mental Health South Carolina Department for the Aging Food Bank for South Carolina (Soup Kitchens) South Carolina Department of Health and Human Services SNP Approval MOC Training, Elements 1-2 January, 2016 16
Questions SNP Approval MOC Training, Elements 1-2 January, 2016 17 MOC 2: Care Coordination Nidhi Dalwadi Mehta MOC 2, Element A: SNP Staff Structure Intent: Describe administrative/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 SNPs care coordination activities in detail SNP Approval MOC Training, Elements 1-2 January, 2016 19 MOC 2, Element A: SNP Staff Structure 1. Describe the administrative staffs roles and responsibilities, including oversight functions. 2. Describe the clinical staffs roles and responsibilities, including oversight functions. 3. Describe how staff responsibilities coordinate with the job title. 4. Describe contingency plans used to address ongoing continuity
of critical staff functions. 5. Describe how the organization conducts initial and annual MOC training for its employed and contracted staff. 6. Describe how the organization documents and maintains training records as evidence that employees and contracted staff completed MOC training. 7. Describe actions the organization takes if staff do not complete the required MOC training. SNP Approval MOC Training, Elements 1-2 January, 2016 20 MOC 2, Element A Example- factor 3 SNP Approval MOC Training, Elements 1-2 January, 2016
21 MOC 2, Element A Example- factor 5 SmartHealths initial and annual MOC training is computer-based. The electronic educational system allows us to log attendance lists and follow up on education delivered. The training incorporates various competencies related to specific job functions. Strategies include web based training modules such as business overview, Integrity and Compliance, Fraud and Abuse, Cultural Competency, HIPPA and Confidentiality. Job function content includes the use of Orientation Guides, directed selfpaced learning, didactic modules, and mentoring for a minimum of 4 weeks as well as classroom training. SNP Approval MOC Training, Elements 1-2 January, 2016
22 MOC 2, Element A Example- factor 7 Failure to complete the training within the designated timeframe may result in corrective actions (CAP) ranging from providing reminder emails about trainings, phone calls to the PCP, and other outreach. SNP Approval MOC Training, Elements 1-2 January, 2016 23 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 Individual Care Plan (ICP) Dissemination of information to Interdisciplinary Care Team (ICT) Process for conducting the initial and annual assessments Methodology used to review,SNP analyze andElements stratify HRA Approval MOC Training, 1-2 January,
2016 24 MOC 2: Element B: Health Risk Assessment Tool 1. How the organization uses the HRAT to develop and update the Individualized Care Plan (ICP) for each beneficiary (Element 2C). 2. How the organization disseminates the HRAT information to the Interdisciplinary Care Team (ICT) and how the ICT uses that information (Element 2D). 3. How the organization conducts the initial HRAT and annual reassessment for each beneficiary. 4. The detailed plan and rationale for reviewing, analyzing and stratifying (if applicable), the HRA
results. SNP Approval MOC Training, Elements 1-2 January, 2016 25 MOC 2, Element B Example- factor 1 SmartHealth utilizes a standardized, comprehensive approach to collecting, analyzing and communicating information collected via the health risk assessment tool (HRAT). The HRAT is a combination of several assessments that focus on the medical, psychosocial, cognitive and functional needs and disabilities of members of our target population and identifies current and future health risks. The HRA is completed by the Care Manager (a Nurse Practitioner (NP), or Registered Nurse (RN)) within 30 days of the members enrollment into the plan and is conducted in the members home. The assessment includes a full medication review (prescribed, over-the-counter medications, vitamins and herbal supplements; discussions with the members PCP occur; review of the HRA for prioritization of problems and interventions and need for community resources,
identification of co-morbidities associated with common conditions found in this dual eligible population such as: chronic obstructive pulmonary disease, cardiovascular disease, cerebral vascular disease and diabetes. SNP Approval MOC Training, Elements 1-2 January, 2016 26 MOC 2, Element B Example- factor 4 SmartHealths care managers, registered nurses, are responsible for reviewing and analyzing the HRA through the system which has the ability to data mine the specific risk criteria. Others involved in the review of member health care needs are those involved in the members ICT such as physicians, nurse practitioners, pharmacists, psychologists, therapists, specialists and social workers. At the member level, the data is reviewed by the ICT which sets the services most appropriate for the member to receive and the frequency of plan to
member outreach. This information allows the Care Manager to identify members needing a higher level of care management, services and monitoring. The health risk profile also allows the Care Manager and ICT to be proactive and target interventions. Using a multidisciplinary team approach structured to address the members particular needs, the ICT, led by the Care Manager, develops the ICP with the involvement of the beneficiary, to the extent possible. Again, the information in the ICP is maintained in member health records and preserved on the organizations secure server. Each ICT member orTraining, ancillary provider SNP Approval MOC Elements 1-2 January, 2016 has 27
access as applicable. 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 SNP Approval MOC Training, Elements 1-2 January, 2016 28 MOC 2, Element C: Individualized Care Plan (ICP) 1. The essential components of the ICP. 2. The process to develop the ICP, including how often the ICP is modified as beneficiaries health care needs change. 3. The personnel responsible for development of the ICP, including how beneficiaries and/or caregivers are
involved. 4. How the ICP is documented, updated and where it is maintained. 5. How updates and modifications to the ICP are communicated to the beneficiary and other SNP Approval MOC Training, Elements 1-2 January, 2016 29 stakeholders. MOC 2, Element C Example- factor 2 Member care plans are reviewed and revised by the members care manager, in coordination with the members primary care practitioner. All members of the ICT are involved in the development and review of the ICP. The member, whenever feasible is a vital component of the ICT and is involved in the development and review of his/her plan of care. In addition, specialists involved in the care of the member are involved in the development and review of the plan of care. Revisions are based upon the hanging health
needs of the member, as identified in the HRA and feedback from providers. Care plans are reviewed and revised according to the following frequency: Every six months, following completion of the Health Risk Assessment. When there has been a change in the members condition (i.e. hospitalization, new onset of chronic condition and change in psycho-social function). Included in the ICP revision is an evaluation of the identified goals and whether they are met. SNP Approval MOC Training, Elements 1-2 January, 2016 30 MOC 2, Element C Example- factor 4 The member care plan is created, maintained, revised, documented and stored in the electronic care management system. It is available to the internal plan staff that are ICT members, such as care managers, social workers and member services specialists. The plan of care is shared with the external ICT either by fax, secure email, by mail or telephonically. The
member is mailed a hard copy of his/her plan of care. External ICT members may also access the members plan of care through the secure web portal on the plan website. Revisions to the care plan are shared in similar methods. The care manager is integral to any and all communications as he/ she coordinates all services included in the care plan with the providers, the PCP and the member. Communication of the care plan occurs at enrollment and continues every six months during the semi-annual assessment of members, in the event of change in condition, new onset of disease, medication changes, completion of set goals and/or interventions, during/after a hospitalization or change in level of care, and referral to behavioral health services. All members of the ICT have the opportunity to review and provide comment on the ICT. The PCP is faxed a copy which SNP Approval MOC Training, Elements 1-2 January, 2016 he/she is asked to sign as evidence of collaboration. Once received by the31
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 SNP Approval MOC Training, Elements 1-2 January, 2016 32 MOC 2, Element D: Interdisciplinary Care Team (ICT) Contd.
1. How the organization determines the composition of ICT membership. 2. How the roles and responsibilities of the ICT members (including beneficiaries and/or caregivers) contribute to the development and implementation of an effective interdisciplinary care process. 3. How ICT members contribute to improving the health status of SNP beneficiaries. 4. How the SNPs communication plan to exchange beneficiary information occurs regularly within the ICT, including evidence of ongoing information exchange. SNP Approval MOC Training, Elements 1-2 January, 2016 33 MOC 2, Element D Example- factor 1
In addition to the member and family/caregivers, the ICT is comprised of various disciplines whose primary purpose is to coordinate the delivery of services and benefits that address the members specific needs. Members of the ICT are determined by analysis of the members initial health risk assessment and/or subsequent follow-up assessments as well as the member's care plan. After a member is enrolled in the plan, he/she is assigned to a care manager. The care managers are registered nurses who all have experience throughout the long term care continuum, including home care. SmartHealth makes every effort to match our members with care managers who have similar cultural and lingual attributes to ensure communication between the two is effective. Depending on the unique needs of the members, the care manager determines the other appropriate members of the members care team. The primary care physician is at the core of the team with specialists added. At a minimum, the ICT members include the member, care manager, primary care physician/practitioner, specialists, home and community-based
services providers, caregivers and/or family and a medical director. In addition, SmartHealth has access to a wide variety of internal team members e.g. health educators, health coaches, pharmacists, nurse practitioners, social workers and behavioral health specialists. These ICT team members work closely with SNP Approval MOC Training, Elements 1-2 January, 2016 34 community based resources that may be added to the ICT as needed. MOC 2, Element D Example- factor 3 ICT contribution to improving the health status of the SNP members by: Analyzing and incorporating the results of the initial and ongoing health risk assessment into an ICP Collaborating to develop and update an ICP for all members. Managing the medical, cognitive, psychosocial, and functional needs of members in a timely, cost-effective manner.
Communicating and coordinating the care plan with members, providers and their caregivers Making recommendations for the members to have access to additional needed services, including participation in intensive care management, chronic care disease and other special programs. After the HRA is complete, the care manager communicates telephonically with the ICT to develop the comprehensive care/service plan for the member Meetings with the member are prescheduled with the members agreement and are coordinated by the care manager. Meetings are scheduled via notices and Microsoft Outlook for all ICT members. Each care manager is responsible for creating the master schedule of ICT meetings for all assigned members as communicatingSNP these meetings to the ICT Approval MOC Training, Elements 1-2 January, 2016
35 MOC 2, Element E: Care Transition Protocols Intent: Describe the SNPs processes to coordinate care transitions and facilitate timely communications across settings and providers. Focus: Describing the type of health care settings and personnel responsible for care transitions How are elements of the members ICP shared between settings and who has access How members and/or caregivers are educated for selfmanagement activities Describe the point of contact throughout the transition process SNP Approval MOC Training, Elements 1-2 January, 2016
36 MOC 2, Element E: Care Transition Protocols Contd. 1. The process for coordinating transitions 2. Personnel responsible for coordination efforts 3. Description of coordination between settings during a care transition 4. How beneficiaries have access to personal health information to facilitate communication with providers 5. Education provided to members/caregivers to manage conditions and avoid transitions 6. Process used to notify members/caregivers of staff assigned to support member through transitions
SNP Approval MOC Training, Elements 1-2 January, 2016 37 MOC 2, Element E Example- factor 2 Health Services Specialists - provide operational and clerical support to the Health Services teams. They distribute faxed clinical review information to nurses; fax the hospital determination log to facilities Inpatient Review Nurses - Case Managers are typically on-site at select hospitals and they conduct medical necessity and discharge planning reviews for members who are admitted. They will also provide information to the member and the members family on what to expect upon discharge and support the member through the transition and discharge process; makes appropriate CM referrals for post discharge follow up (telephonic review, Care Transition Coaching
and others (i.e., Complex Care Management Program, behavioral health; report any potential Quality of Care issues Care Transition Coach (CTC) - is a nurse or social worker who follows patients across care settings after leaving the hospital as part of the Care Transitions Coaching program. SmartHealth's Case Management SNP Approval MOC Training, 1-2 January, 2016 department has adopted the strategies designed toElements ensure proper 38
MOC 2, Element E Example- factor 4 Members who complete the HRA tool are mailed care plans and they are encouraged to share them with their providers to facilitate communication during the transition process. These care plans are written at or below a 6th grade reading level to ensure that members are able to use and understand them. In these letters, members are provided with the telephone number and contact information for the Care Management department. Care managers can work with the member or caregiver to update the care plan, mail updated care plans to the member or share care plan information with the members PCP or treating physician in any care setting. Members are also encouraged to complete and maintain their Personal Health Record (PHR) which contains member goals, a medication list, allergies, questions for providers, member conditions and red flags and should be shared at all visits to the members doctor or to the treating facility. SmartHealth works with members to complete the PHRs and ensure that they
understand how to use them. Finally, SmartHealth developed an online member portal that has the capability to care plans SNP share Approval MOC Training, Elementswith 1-2 January, 2016 39 members and caregivers. MOC 2, Element E Example- factor 6 The use of SmartHealths online portal will allow both members and family members to have access to their medical record, members of their ICT and changes in
transition of care. When a member experiences a transition in care, they are immediately transferred to the transition team who contacts the family members as well as the new setting (i.e. hospital, rehabilitation center) to see what the plan of care is as well as a potential discharge date. This is documented in the care management system. A social worker is sent out to the new setting to evaluate member and reach out to the D/C planners to maintain optimal contact/planning. The members care manager is the point of contact for the member and/or caregivers throughout the transition process. This is communicated to the beneficiary SNP Approval MOC Training, Elements 1-2 January, 2016 40 and family via phone calls by the care manager to stay in Questions?
SNP Approval MOC Training, Elements 1-2 January, 2016 41 HPMS Review Susan Radke HPMS Review Contract Management Tab SNP Approval MOC Training, Elements 1-2 January, 2016 43 HPMS Review Models of Care
SNP Approval MOC Training, Elements 1-2 January, 2016 44 HPMS Review Select an MOC to Upload SNP Approval MOC Training, Elements 1-2 January, 2016 45 HPMS Review Select MOC File for Upload SNP Approval MOC Training, Elements 1-2 January, 2016 46
HPMS Review MOC File Upload Confirmation SNP Approval MOC Training, Elements 1-2 January, 2016 47 HPMS Review Submission Renewal SNP Approval MOC Training, Elements 1-2 January, 2016 48 HPMS Review MOC Detailed Report SNP Approval MOC Training, Elements 1-2 January, 2016
49 Training & Education Sessions focus on MOC Requirements & Technical Assistance -- MOC Elements 1 & 2 (1 training) o January 12, 2016, 3:00-4:30pm EST -- MOC Elements 3 & 4 (1 training) o January 14, 2015, 3:00-4:30pm EST
-- Technical Assistance Calls scoring <70% 3:004:30pm EST for SNPs February 9, 2016 Recordings and slides available on NCQA SNP Approval website within one week of call o April 21, 2016 o SNP Approval MOC Training, Elements 1-2 January, 2016 50 CMS Contacts For technical inquires related to the MOC program plan
requirements, or other issues related to the SNP approval proposal in the regulations, please contact CMS at: https://dpap.lmi.org. In the subject line enter: SNP MOC Inquiry For SNP application inquiries via the CMS SNP mailbox: please type https://dmao.lmi.org into your web browser, then select the SNP mailbox. Subject line: SNP Application Inquiry CMS MMP mailbox: [email protected] Subject line: MMP MOC Inquiry For training recordings and slides: please visit the NCQA SNP Approval Website at: https://www.snpmoc.org SNP Approval MOC Training, Elements 1-2 January, 2016 51
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