2016 Model of Care Overview and Executive Summary.

Transcription

1 2016 Model of Care Overview and Executive Summary

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3 Table of contents Description of Keystone VIP Choice...1 Annual evaluation process...3 Key findings and recommendations...4 Goal 1: Improving access to essential services...7 Goal 2: Improving access to affordable care...9 Goal 3: Improving coordination of care through an identified point of contact...11 Goal 4: Improving seamless transitions of care...13 Goal 5: Improving access to preventive health services...15 Goal 6: Improving member health outcomes...17 Goal 7: Improving appropriate utilization of services...19 Conclusion for 2016 MOC annual evaluation:...21

4 Under the Medicare Modernization Act of 2003 (MMA), Congress created a new type of Medicare Advantage coordinated care plan focused on individuals with special needs. AmeriHealth Caritas received approval from the Centers for Medicare & Medicaid Services (CMS) to offer a dual eligible special needs plan (D-SNP) beginning on January 1, The Medicare VIP D-SNP became effective for members in eight counties, serving beneficiaries in Pennsylvania in two service areas.

5 Description of Keystone VIP Choice The AmeriHealth Caritas Medicare VIP Plans H4227 Special Needs Plan serves dual Medicare and Medicaid beneficiaries in two service areas, designated as Keystone VIP Choice and AmeriHealth VIP Care. Individuals eligible for the D-SNP are entitled to receive Medical Assistance under title XIX and reside in the AmeriHealth Caritas service area. Keystone VIP Choice is responsible for providing benefits or arranging for benefits for all its plan beneficiaries. Keystone VIP Choice integrates specialized care delivery systems across all domains to improve health outcomes, lower costs, and have a positive impact on the overall health and quality of life for members Model of Care Overview and Executive Summary 1

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7 Annual evaluation process Keystone VIP Choice follows a CMS-approved Model of Care (MOC), which describes the care and resources to be provided to members of the health plan. As a D-SNP, Keystone VIP Choice is responsible for conducting an annual evaluation of programs. The MOC oversight group is comprised of representatives from key departments (e.g., Quality Management, Medical Management, Member Services, Medical Economics, Compliance, and Provider Relations) and collects, analyzes, and reports on data that is used to evaluate the effectiveness of the MOC towards goals. In this process, the MOC oversight group develops key findings and identifies any follow-up actions needed. Keystone VIP Choice utilizes various tools to measure and track the progression of goals and timely identification of barriers. These include reports at both the aggregate and detail levels performed during various time frames (monthly, quarterly, biannually, and annually). The outcomes of the goals are measured utilizing a variety of tools, including, but not limited to, the Health Risk Assessment (HRA), chart audits, hospitalization utilization, satisfaction and health outcomes survey questions, call center statistics, pharmacy and plan benefit reviews, and interim Healthcare Effectiveness Data and Information Set (HEDIS ) measures. The results are summarized at an organizational level to identify areas of strength and opportunities to improve the MOCs for each of the individual goals measured. This evaluation assesses progress and goals in the following areas: A. Improving access to essential services. D. Improving seamless transitions of care. B. Improving access to affordable care. C. Improving coordination of care through an identified point of contact. E. Improving access to preventive health services. F. Improving beneficiary health outcomes. G. Improving appropriate utilization of services Model of Care Overview and Executive Summary 3

8 KEY FINDINGS AND RECOMMENDATIONS 4 Keystone VIP Choice

9 2016 Model of Care Overview and Executive Summary 5

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11 Goal 1: Improving access to essential services Keystone VIP Choice strives to facilitate the provision of and access to appropriate, timely, and cost-effective health care services and treatment in the least restrictive setting and manner. When health care needs can be anticipated and identified early in the continuum of care, members can often be assisted with less intense and intrusive services. By working closely with the member and/or caregiver, primary care provider (PCP), and ancillary providers, the Care Manager can anticipate required services, arrange these to be provided in the most cost-effective setting, and provide quality care to meet the member s health care needs. Keystone VIP Choice s MOC analysis has determined that some goals in this area were met, including the number of providers in the plan s network and the maximum driving times and distances for members. Provider access and after-hours care goals have not fully been met during Based on the results achieved, Keystone VIP Choice will continue to assess the performance indicators and revise goals that do not provide measurable data. Barriers continue to be low membership in several measures. Planned interventions for 2017 include developing enhanced performance reports and improved provider educational materials related to members who have suffered a fracture, as well as ensuring members have proper after-hours access to providers. The plan will also collaborate with the pharmacy vendor to improve targeted member outreach campaigns and revise goals that do not support data analysis Model of Care Overview and Executive Summary 7

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13 Goal 2: Improving access to affordable care Access to affordable care is essential to the D-SNP population. Monitoring network adequacy and medication pricing can help identify opportunities for improvement at the plan. Keystone VIP Choice s MOC oversight group has determined that the overall goal has not fully been met; however, they recognized accomplishments toward these goals. In 2016, the plan met or exceeded the standards for beneficiary access to PCPs and highvolume specialists. Review of drug plan prices on the plan s website achieved a 99 percent rating; however, this fell below the goal of 100 percent for a five-star achievement. Barriers and plans for improvement will include coordination with pharmacy delegation oversight reporting and developing action plans for barriers identified by the pharmacy benefits manager (PBM) to achieving a five-star rate Model of Care Overview and Executive Summary 9

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15 Goal 3: Improving coordination of care through an identified point of contact Care coordination is a vital part of developing a strong relationship with Keystone VIP Choice beneficiaries. Developing goals through a customized plan of care (POC) from a skilled Nurse Care Manager helps to demonstrate our commitment to improving the overall health of our members with chronic or complex conditions. Our oversight group has determined that this overall goal has not been met. They therefore recommend reviewing the established goals and performance metrics outlined in the MOC and enhancing them. Keystone VIP Choice recognizes the importance of increasing member care management participation rates and providing quality services, including member assessments, care planning, and a care team. New members of Keystone VIP Choice must complete an initial health assessment within 90 days of their effective membership. Although the 43 percent completion rate for this metric represented a great improvement over the 2015 rate, this still did not meet the plan s overall five-star goal of 92 percent. The 2016 existing member engagement rate was calculated at 38 percent; however, due to care coordination reporting improvements and data tracking changes, success is difficult to measure at this time. The plan met its goal for completing the initial health assessment within 90 days among members we were able to reach and members who did not opt out of the program. The 2016 rate will be used as a baseline for measuring 2017 progress. Based on the results achieved, Keystone VIP Choice will continue planned efforts to improve transitions of care across settings and work with providers to follow evidence-based guidelines. Goals for 2017 include increasing engagement rates by 5 percent or higher for high-risk members and completing 100 percent of initial HRAs within 90 days and 100 percent of annual reassessments within 365 days of prior assessment Model of Care Overview and Executive Summary 11

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17 Goal 4: Improving seamless transitions of care Care Managers coordinate updates to each member s Plan of Care (POC). The information used to update the POC can come from the member or caregiver, another member of the interdisciplinary care team, or a facility or agency involved in a care transition. When a member moves from an inpatient care setting back to outpatient management, the Care Manager incorporates the information from the facility or discharge planner (such as medication orders or treatment prescriptions) into the POC. We established internal reports to measure the percentage of members with a PCP follow-up visit after discharge. Final results for 2016 varied from 2015 in the percentage of members with a follow-up PCP visit within the following time frames: PCP follow-up visit within seven days of discharge improved.39 percent. PCP follow-up visit within 14 days of discharge decreased by.61 percent. PCP follow-up visit within 30 days of discharge decreased by.62 percent. Planned interventions will continue increasing Care Management staff engagement with members after discharge and investigate additional in-home transition of care services for members Model of Care Overview and Executive Summary 13

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19 Goal 5: Improving access to preventive health services HEDIS results for calendar year 2016 (HEDIS 2017) show improvements from calendar year 2015 (HEDIS 2016). Keystone VIP Choice provides abundant access to preventive health services through the provider network and its complement of covered benefits. Members are encouraged through member newsletter articles, provider outreach, and Care Managers to complete preventive services and screenings. HEDIS indicators demonstrate year over year improvement of the collective efforts of Keystone VIP Choice and its provider network to assist members in accessing preventive health services. Improvement from the prior year is noted for breast cancer screenings and body mass index assessments. Identified opportunities for improvement were found for colorectal cancer screenings and annual flu vaccinations. The MOC oversight group determined this overall goal has not been met. Based on the results achieved, Keystone VIP Choice will continue planned efforts to improve access to preventive health services and monitor individual measures that did not meet the goals Model of Care Overview and Executive Summary 15

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21 Goal 6: Improving member health outcomes Member health outcomes are evident through a variety of measurement sources. The measures that are chosen to establish whether the member is improving or maintaining his or her health are derived from reliable CMS surveys and clinical data. Health outcomes are often influenced by member self-perception of health and support, which is measured by CMS in the Health Outcomes Survey. Medicare Health Outcome Survey results for the 2016 Cohort 19 Baseline Report noted that: 42.6 percent of members surveyed indicated their general health was excellent to good percent of members surveyed indicated their physical health was much better to about the same percent of members surveyed indicated their mental health was much better to about the same. HEDIS measures are also used by the plan to measure the improvement of health outcomes. HEDIS measures for diabetic disease management, coronary artery disease management, chronic obstructive pulmonary disease (COPD) management, and controlling hypertension were reviewed with the goal of achieving the 90th national average or a CMS five-star cut point level. Improvement from the prior year was noted for diabetes management, including nephropathy testing. The percentage of members completing a diabetic eye exam and an HbA1C test decreased in The MOC oversight group determined this overall goal has not been met. The measures that are a composite of the goal are under evaluation. Since some measures had insufficient data, other metrics will be chosen Model of Care Overview and Executive Summary 17

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23 Goal 7: Improving appropriate utilization of services Keystone VIP Choice maintains a robust utilization management (UM) program to assess the need for care, assist members with arrangements for services, and connect members to other VIP programs, including care management and chronic care improvement programs. The UM program is evaluated annually to assess its strengths and effectiveness. A UM program evaluation is prepared and presented to the Quality Assessment Performance Improvement Committee. This information is used to update and revise the UM program description annually. The UM staff is responsible for intake, prior authorization, and concurrent review. MOC program goals for improving appropriate utilization of services included inter-rater reliability testing and review of inpatient and outpatient utilization rates. We used inter-rater reliability testing to ensure that clinical reviewers make objective and consistent medical necessity decisions for proper utilization of services by members. Inter-rater reliability testing helps create a degree of objectivity within the plan. In 2016, inter-rater reliability testing was completed quarterly. The testing resulted in a success rate average of 100 percent. In meeting the goal of improving appropriate utilization of services, the following goals were achieved: Utilization management review decisions for non-urgent pre-service requests were completed within 14 days or less 100 percent of the time. Utilization management review decisions for urgent pre-service requests were completed within 72 hours or less 100 percent of the time Model of Care Overview and Executive Summary 19

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25 Conclusion for 2016 MOC annual evaluation The AmeriHealth Caritas MOC annual evaluation oversight group has concluded that overall goals have not been met in 2016; however, great improvement in several areas was observed. We will develop initiatives to address goals that were not met. Follow-up is expected where opportunities for improvement were noted with recommended action steps. These actions and performance monitoring are to be reported in subsequent Quality Assessment Performance Improvement Committee meetings Model of Care Overview and Executive Summary 21

26 Keystone VIP Choice 200 Stevens Drive Philadelphia, PA KVIPCPA