2015 Model of Care Overview and Executive Summary.

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1 2015 Model of Care Overview and Executive Summary

2 Our vision: Leading America in health care solutions for the underserved. Our mission: We help people get care, stay well, and build healthy communities. Our values: Advocacy, care of the poor, compassion, competence, dignity, diversity, hospitality, and stewardship.

3 Table of contents Background... 1 Description of AmeriHealth Caritas VIP Care Plus... 1 Annual Model of Care evaluation process... 1 Key fndings and recommendations... 5 Access to essential services... 7 Access to afordable care... 7 Coordination of care through an identifed point of contact... 9 Seamless transitions of care...11 Access to preventive services...13 Benefciary health outcomes...15 Appropriate utilization of services Model of Care annual evaluation summary...19

4 Under authority of the Patient Protection and Afordable Care Act of 2010, the Centers for Medicare & Medicaid Services (CMS) launched the Demonstration Initiative to Integrate Care for Persons Eligible for Medicare and Medicaid. The Demonstration Initiative is testing innovative payment and service delivery models to improve coordination of services, enhance quality of care and life, reduce health disparities, and reduce costs. AmeriHealth Michigan Inc. received approval from CMS and the Michigan Department of Health and Human Services (MDHHS) to ofer AmeriHealth Caritas VIP Care Plus beginning May 1, 2015, as a dual eligible Medicare- Medicaid plan as part of the Demonstration Initiative Model of Care Overview and Executive Summary

5 Description of AmeriHealth Caritas VIP Care Plus Individuals eligible for AmeriHealth Caritas VIP Care Plus are at least 21 years old, reside in the service area, are eligible for full benefts under Medicare Part A and are enrolled under Parts B and D, and are receiving full Medicaid benefts. AmeriHealth Caritas VIP Care Plus is responsible for providing benefts or arranging for benefts for plan enrollees consistent with the expectations and requirements of the Demonstration Initiative. Annual Model of Care evaluation process AmeriHealth Caritas VIP Care Plus has created a CMS-approved Model of Care (MOC) program that is an evidence-based integrated care management approach for delivery of health care services. The MOC program describes the care and resources to be provided to plan enrollees. Goals for 2015 MOC program activities were identifed in the following areas of focus: 1. Access to essential services. 2. Access to afordable care. 3. Coordination of care through an identifed point of contact. 4. Seamless transitions of care. 5. Access to preventive health services. 6. Benefciary health outcomes. 7. Appropriate utilization of services Model of Care Overview and Executive Summary 1

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7 AmeriHealth Caritas VIP Care Plus is responsible for conducting an annual evaluation of the MOC program. The evaluation is completed by an oversight group consisting of representatives from key departments including, but not limited to, Quality Management, Medical Management, Provider Network Management, Member Services, Medical Economics, and Compliance. The role of the MOC oversight group is to establish goals for the MOC program and evaluate its efectiveness through the collection and analysis of performance data. In this process, the MOC oversight group develops key fndings, identifes any follow-up actions needed, and reports its fndings to the AmeriHealth Caritas VIP Care Plus Quality Assessment Performance Improvement (QAPI) Committee and Board of Directors. AmeriHealth Caritas VIP Care Plus utilizes various tools to measure and track the progress of goal achievement and identify barriers, strengths, and opportunities for improvement. These tools include aggregate and detailed reports for diferent time frames (monthly, quarterly, semi-annually, and annually). Outcomes are measured using a variety of tools, including, but not limited to, health risk assessments, medical record audits, service utilization, results of the Consumer Assessment of Healthcare Providers and Systems (CAHPS ) survey and Health Outcomes Survey (HOS), call center statistics, enrollee grievance and appeal data, pharmacy data, and Healthcare Efectiveness Data and Information Set (HEDIS ) measures. Many of the program goals were not met for 2015 due to the program start date of May 1, 2015, which did not provide adequate time for measurements that required a full year of data. In addition, some of the goals originally identifed were not applicable to the fnal program design Model of Care Overview and Executive Summary 3

8 KEY FINDINGS AND RECOMMENDATIONS Model of Care Overview and Executive Summary

9 2015 Model of Care Overview and Executive Summary 5

10 Model of Care Overview and Executive Summary

11 Access to essential services AmeriHealth Caritas VIP Care Plus strives to facilitate provision of and access to appropriate, timely, and costefective health care services and treatment in the least restrictive settings and manners. When health care needs can be anticipated and identifed early in the continuum of care, enrollees can often be assisted with less intensive and intrusive services. By working closely with the enrollee and his or her caregiver, primary care provider (PCP), ancillary providers, the Behavioral Health Supports Coordinator, and the Long-Term Services and Supports (LTSS) Coordinator, the Care Coordinator can anticipate required services, arrange for these to be provided in the most cost-efective settings, and facilitate quality care to meet the enrollee s health care needs. The goals and benchmarks identifed for access to essential services were dependent upon HEDIS measures and the results of the CAHPS survey and the HOS. HEDIS measures were not applicable, and the surveys were not required in AmeriHealth Caritas VIP Care Plus has reassessed and revised the goals and benchmarks for HEDIS measures are reported and analyzed consistently, and the CAHPS survey and the HOS were completed, with results pending. Access to affordable care Monitoring network adequacy is essential to ensuring access to afordable care for plan enrollees. AmeriHealth Caritas VIP Care Plus met or exceeded required access standards to PCPs and high-volume specialists in AmeriHealth Caritas VIP Care Plus will continue to monitor network adequacy in 2016 to identify and address opportunities for improvement Model of Care Overview and Executive Summary 7

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13 Coordination of care through an identified point of contact Care coordination is an essential part of the care management process. In partnership with the enrollee, a Care Coordinator develops an individual integrated plan of care to help establish a relationship with the enrollee, ensure the enrollee s needs are identifed and addressed, and identify appropriate goals. The following 2015 MOC goals were met specifc to coordination of care for those members the plan could locate who were willing to participate: Identify and enroll benefciaries with chronic or complex conditions into the plan s care management program. Document input into their plans of care for 100 percent of benefciaries. Document fve or more care management interactions during the frst six months of their care management experience for 50 percent of benefciaries. Document communication from 100 percent of benefciaries with key members of their care teams in the languages benefciaries prefer. Goals not met will be re-evaluated and revised as needed. Necessary processes and systems not in place will be implemented and monitored Model of Care Overview and Executive Summary 9

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15 Seamless transitions of care Care Coordinators are responsible for ensuring continuity of care. When an enrollee experiences a planned or unplanned transition of care, a Care Coordinator will maintain the appropriate channels of communication and ensure enrollee needs are identifed and addressed timely and care is not interrupted. In addition to working with the enrollee and/or caregiver, the Care Coordinator works closely with the discharge planner at the facility or agency, the H0192 utilization management nurse, the PCP and/or specialists involved in the enrollee s care, and the Behavioral Health and LTSS Supports Coordinators to update the health risk assessment and plan of care. In 2015, the overall MOC goals specifc to seamless transitions of care were not met. Some goals were not applicable; others were not possible due to plan start date. Not all benchmarks existed as identifed. Goals not met will be re-evaluated and revised as needed. Necessary processes and systems not in place will be implemented and monitored Model of Care Overview and Executive Summary 11

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17 Access to preventive health services In 2015, the overall MOC goals specifc to access to preventive health services were not met. All goals identifed were related to HEDIS measures, some of which were retired and no longer valid and others not applicable to the plan population. In addition, processes to collect and monitor HEDIS data were not fully implemented until the end of the year, as AmeriHealth Caritas VIP Care Plus did not meet the requirements to report HEDIS measures in The Care Coordinator ensures preventive health care needs are identifed for each enrollee and incorporates information on an enrollee s needs into his or her plan of care. Enrollees are also encouraged to complete preventive health services and screenings through provider outreach, member newsletter articles, and focused reminders by mail, such as reminders for cancer screenings. Goals not met will be re-evaluated and revised as needed. AmeriHealth Caritas VIP Care Plus will continue to review monthly HEDIS reports and identify and address opportunities for improvement. AmeriHealth Caritas VIP Care Plus will continually assess the plan population to ensure appropriate services are identifed and addressed to improve and maintain enrollees health Model of Care Overview and Executive Summary 13

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19 Beneficiary health outcomes In 2015, the overall MOC goals specifc to benefciary health outcomes were not met. All goals identifed were related to HEDIS measures, some of which were retired and no longer valid and others not applicable to the plan population. In addition, processes to collect and monitor HEDIS data were not fully implemented until the end of the year, as AmeriHealth Caritas VIP Care Plus did not meet the requirements to report HEDIS measures in AmeriHealth Caritas VIP Care Plus met the goal for the measure to decrease the use of drugs with a high risk of side efects when there may be safer drug choices. Goals not met will be re-evaluated and revised as needed. AmeriHealth Caritas VIP Care Plus will continue to review monthly HEDIS reports and identify and address opportunities for improvement. AmeriHealth Caritas VIP Care Plus will continually assess the plan population to ensure appropriate services are identifed and addressed to improve outcomes Model of Care Overview and Executive Summary 15

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21 Appropriate utilization of services In 2015, the overall MOC goals specifc to appropriate utilization of services were not met. Some goals identifed were dependent upon 12 months of data, which was not available due to the plan s efective date being May 1, One goal that was met with a rate of 96 percent was meeting an internal threshold of 90 percent, through inter-rater testing, of nurses, social workers, and physicians participating in medical necessity determinations. Inter-rater reliability testing ensures that Utilization Management staf makes objective and consistent medical necessity decisions for proper utilization of services by enrollees. Goals not met will be re-evaluated and revised as needed. AmeriHealth Caritas VIP Care Plus will develop enhanced reporting capabilities to monitor denials due to lack of medical necessity to identify trends or opportunities for improvement, including provider education Model of Care Overview and Executive Summary 17

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23 2015 Model of Care annual evaluation Overall goals were not met for The 2015 MOC program was written prior to the plan s efective date as part of the contracting and readiness process and therefore addressed potential future states. As a result, many goals were not applicable, and some were not achievable before the end of the year due to limitations with data collection and process implementation. Improvements to the communication plan regarding the purpose and signifcance of the MOC program were identifed and implemented to increase understanding of the MOC program among staf and providers. AmeriHealth Caritas VIP Care Plus has reassessed all goals to include those that address the specifc needs of the plan population and align with other requirements as much as possible. Benchmarks have been modifed to balance challenge with realistic expectations for improvement. AmeriHealth Caritas VIP Care Plus will re-evaluate the MOC program and goals on a regular basis throughout This will allow AmeriHealth Caritas VIP Care Plus to identify the need for additional improvement actions and revisions in a timely manner. Follow-up is expected where opportunities for improvement were noted with recommended action steps. AmeriHealth Caritas VIP Care Plus will report these actions to the Quality Assessment Performance Improvement Committee Model of Care Overview and Executive Summary 19

24 AmeriHealth Caritas VIP Care Plus 100 Galleria Ofcentre, Suite 210 Southfeld, MI ACVIPCPMI