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Special Needs Plan Model of Care(SNP - MOC)
November 21, 2017
© 2017 Chinese Community Health Plan
Learning Objectives
• To gain an understanding and comprehension of CCHP's Special Needs Plans (SNPs)
• To describe the product offerings provided to CCHP SNP members. • To gain an understanding and comprehension of the Elements of the
SNP Model of Care. • At the end of this training, you will be able to describe the best
practices for the SNP Model of Care.
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Special needs plan model of care elements
Element 1: Description of the SNP populationA. Sub-Population: Most Vulnerable Beneficiaries
Element 2: Care Coordination A. SNP Staff Structure B. Health Risk Assessment Tool C. Individualized Care Plan (ICP)D. Interdisciplinary Care Team (ICT)E. Care Transitions Protocol
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Model of Care elementsElement 3: SNP Provider Network
A. Specialized ExpertiseB. Use of Clinical Practice Guidelines and Transition ProtocolsC. MOC Training for the Provider Network
Element 4: Quality Measurement and Performance Improvement A. MOC Quality Performance Improvement PlanB. Measurable Goals and Health Outcomes C. Measuring Patience Experience of Care (satisfaction) D. Ongoing Performance Improvement EvaluationE. Dissemination of SNP Quality Performance
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• Frail elderly• High risk • Low-income literacy and socioeconomic status• Multiple chronic and acute health problems• Poor diet medication and treatment plan non compliance• Lack of work or pension, inability to work• Lack of family support• Chinese language • Mental illness• Barriers to access to community resources and support
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SNP MOC responds to our missionProvide high-quality, affordable healthcare through
culturally competent and linguistically appropriate services
CCHP SNP-MOC Senior Select membership
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5172, 23% 11771, 53%
2436, 11%
2804, 13%
CCHP Commercial
CCHP Covered CA
CCHP Senior
CCHP Senior Select
• Special Needs Plans are specialized Medicare Advantage plans for beneficiary with special circumstances. A SNP can be one of 3 types:§ Chronic SNP (C-SNP) for members with severe or disabling chronic
conditions.§ Institutional SNP (I-SNP) for members requiring an institutional level of
care or equivalent living in the community.§ Dual-Eligible SNP (D-SNP) for members eligible for Medicare and
Medicaid.
• Model of Care is CCHP’s comprehensive plan for delivering our integrated care management program for our special needs member.
• It is the architecture for promoting quality, care management policy and procedures, and operational systems.
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What is SNP Model of Care?
• CCHP offers a D-SNP named “CCHP Senior Select Program (HMO SNP)”
§ Enrollees must have Medicare and Medicaid benefits§ Offered in San Francisco§ Current membership is 3,053 members§ Enrollees in this D-SNP are responsible for $0 for
covered medical services
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CCHP is a Dual Eligible SNP (D-SNP)
IdentifyMostVulnerableBeneficiaries
• Age gender ethnicity• Incidence and prevalence
of major diseases • Chronic conditions• Barriers of language health
literacy access to care• Cultural beliefs or
socioeconomic status
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• Multiple hospital admissions• High pharmacy utilization, • high cost medical,• psychosocial, cognitive and functional
challenges
• Marketing and Sales by CCHP • Enrollment applications directly from sales agent• Enrollment and Eligibility Department reviews application to
ensures Medicare and Medi-Cal beneficiary• When Medicare beneficiaries obtain Medi-Cal eligibility, the
beneficiary is encouraged to join the SNP plan• Initiate coordination of Medicare and Medi-Cal benefits beg• Members in CCHP Senior Select SNP MOC are
responsible for $0 for covered medical services
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Where We Start: Enrollment & Eligibility
• Access to medical, mental health, and social services.• Access to affordable care.• Coordination of care through an identified point of contact.• Transitions of care across continuum.• Access to and utilization of preventive health services.• Appropriate utilization of services.• Quality outcomes.• CCHP maintains a comprehensive network of primary care
physicians, specialists and non-physician practitioners to meet the health needs of chronically ill, frail and disabled SNP members.
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CCHP’s D-SNP Goals
CCHP MOC Summary§ Dedicated care manager§ Support for complying with the PCPs plan of care§ Disease-specific education guidance and materials
(English and Chinese)§ How to recognize and alleviate warning signs and
symptoms § Education supporting medication adherence§ Advanced care planning§ Connection to community resources
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The Member§ Consents to receive calls from Care Coordination team.§ Option to opt out of receiving calls (continue to make attempts
annually or with change in health status).§ Participates in the development of an ICP (Individualized
Care Plan) by completing their initial or annual HRA.§ Participates in the Interdisciplinary Care Team (ICT) through
communication with the Care Coordinator.
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Member Centered Model of Care
Current Corrective Action Plan
§ Implementation of Measurable goals and specific services and interventions
§ Personalized care plan promoting self-care and participation of caregivers
§ Individual unique ICP tailored to the members needs § Establish specific goals with agreed upon targets for
completion§ Free-form text to address the specific needs/goals
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• Self-reported survey includes questions on medical, psychosocial, cognitive, functional and mental health.
• New enrollees are sent the initial HRA and given 90 calendar days to complete and annually and if there is a change in the members’ condition or transition of care.
• If the HRA is not returned within 1 month, a minimum 3 attempts are made to complete the HRA telephonically.
§ After 3 unsuccessful attempts, an “unable to reach” letter is sent to inform the member of the multiple attempts to reach the member.
• Stratify member into risk categories for care coordination§ HRA is shared with members of the Interdisciplinary Care Team
(ICT) including the member, caregiver and provider.§ HRA provides the basis for the ICP.
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Health Risk Assessment
HRA Sample
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• HRA responses used to develop/update the ICP• Claims and pharmacy data used to develop the member’s ICP
when they do not respond to the HRA.• ICT evaluates and analyze data to focus care and improve
quality and risk scores• ICP is maintained and stored to assure access by all care
providers and meet HIPAA and professional standards• ICP includes:
v Member’s health care preferences v Goals and objectives and targets with detailed tasks and
self-management plans v Interventions and services tailored to member’s unique
and individual needsv Documentation if time-bound goals met or not met
• Evidence-based Milliman Care Guidelines (MCG
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Development of Individualized Care Plans (ICP)
ICP goals based on the SMARTS Measurable Goal Model: 1. Specific – Exactly what is to be learned/accomplished by the
member.2. Measurable – A quantifiable goal and specific result that can be
captured reported and documented in the ICP.3. Attainable – Goal is achievable by the member.4. Relevant – Goal is clearly linked to health status.5. Time-Bound – The deadline or time period to motivate and evaluate
is specific in terms of specific date, number of days/weeks/months or calendar year.
6. STARS HEDIS – Measures that contribute to CCHP quality scores
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Individualized Care Plan Goals Model
• DocumentationinthecaremanagementsystemICP is updated if a change in the member’s health status or at a minimum annually.
• ICP updates and changes are communicated to the member, caregiver(s) and primary care provider.
• Documentationinthemember’sICP with a copy of the member’s ICP sent to the member and the PCP.
• Members that do not respond to the HRA will receive an ICP based in part with pharmacy and medical claims data
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Individualized Care Plan…cont.
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ICP Sample
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• Providers are asked to sign and return the Physician Care Plan Signature page to Care Coordination department if they agree with the care plan.
• If the provider does not sign and return the signature page in two (2) weeks the care plan is considered accepted.
ICP Provider Statement
• All staff are trained on the SNP MOC initially and again annually§ Sales/Marketing/Enrollment. Ensure beneficiaries enroll into plans and
products that suit their special needs§ Coordinators. Non-clinical administrative staff assist beneficiaries and
coordinate access to services. § Social Workers. Address psychosocial issues access to low or no cost
community resources, housing programs, appointments with network and out of network social workers, psychologists, psychiatrists and other mental health services.
§ Nurses. Contact communicate and coordinate care; post-discharge, disease and case management and health education.
§ Clinical Informatics. Analyze HRA risk scores interpret and target interventions; mailings to members and providers.
§ UM Manager and Director of Clinical Services. Ensure implementation and communication of the SNP MOC.
§ Compliance Officer. Ensures compliance with all CMS contract and regulatory requirements.
§ Medical Director. Responsible for administrative performance compliance and care delivery services to ensure high quality of care for all beneficiaries.
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Interdisciplinary Care Team (ICT) and Staffing
Networkproviders
• Through policies and procedures ensures that providers are fully credentialed• Participate in the member’s ICT as needed• Incorporate relevant clinical information in the member’s ICP• Follow transition of care protocols• Use MCGs clinical practice guidelines• Receive regularly scheduled WebEx MOC training• Annualreviewofdelegatedgrouputilizationdecisionsmemberappealsprocess• ReviewofpatientmedicationprofilesinaMedicationTherapyManagement(MTM)Program• Stars and HEDISoutcomesreporting• SatisfactionsurveystoassessandreportsatisfactionwiththeMOC• ReportedmeasuresusedtomodifytheMOCQIPonanannualbasis
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• Post Discharge Program• Disease and Case Management • Focus on the top 4 conditions:
§ Heart Failure (CHF)§ Chronic Obstructive Pulmonary Disease (COPD)§ Diabetes§ End Stage Renal Disease (ESRD)
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Care Coordination Program
• Members are at increased risk of adverse outcomes when transitioning from one care setting (admission or discharge from a hospital, skilled nursing, rehabilitation center or home health.)
• When the member is discharged home, the Care Coordinators conduct post-discharge calls within 1 business day of discharge to review changes to the member’s care plan
• Assist with discharge needs, review medications and encourage follow-up care with the healthcare provider within 5 days of discharge.
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Care Transition: Post-Discharge Program
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• Performs an assessment of medical, psychosocial, cognitive, functional, and mental health needs and status
• Develops a comprehensive ICP• Identifies barriers to goals and
strategies to address• Provides personalized education
for optimal wellness• Encourages preventive care
• Reviews and educates on medication regimen
• Promotes appropriate utilization of benefits
• Assists member to access community resources
• Assists caregiver when member is unable to participate
• Provides a single point of contact during care transition
Care Coordination Activities
Quality
• Goals are in alignment with the Medicare and Medicaid regulatory agencies performance measurement systems
• STARS, Consumer Assessment of Healthcare Providers and Systems (CAHPS) Healthcare Effectiveness Data and Information Set (HEDIS)
• Health Outcomes Survey (HOS)
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Summary
• MOC needs to be YOUR model for managing care for your members
• The model supports the mission of CCHP and its business objectives
• Needs to be an integral to care management, member services, network management/provider relations, risk adjustment, management, Quality improvement and marketing.
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References
• Chapter 5 of the Medicare Managed Care Manual• Title 42, Part 422, Subpart D, 422.152• www.cms.gov/Medicare/HealthPlans/SpecialNeedsPlans• Model of Care Scoring Guidelines CY 2018 (2/10/17)• Chapter 16B Special Needs Plans of the Medicare Managed• CCHP Policies and Procedures
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After you have completed the training module, please print this page. Read and sign this Attestation Statement and return to CCHP Care Coordination via fax at 415-955-8815.
I acknowledge that I have completed the 2017 SNP MOC Provider Training.
_______________________Print Name
_______________________ ______________Signature Date Completed
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Training Attestation
Contacts and information
• [email protected]• [email protected]• [email protected]• [email protected]
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THANK YOU
