Model of Care. Quality Department 2017

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1 Model of Care Quality Department

2 Objectives Understand the four (4) Model of Care elements, aimed at improving healthcare for D-SNP members. Learn about the Model of Care that MCS offers to their members with dual eligible (D-SNP) Learn about the role and integration of the providers in the MCS Model of Care. 2

3 Special Needs Plans Background Under the Medicare Modernization Act of 2003 the U.S. Congress developed the Special Needs Plan (SNP), as part of the requirements for the Medicare Advantages (MA). Dual elegible (D-SNP) Chronic (C-SNP) Institucionalized (I-SNP) Under the 2012 Affordable Care Act, which amended Section 1859(f) of the Social Security Act Requiered that all SNPs must be approved by NCQA (National Committee for Quality Assurance) CMS requires that all Medicare Advantage with D-SNP develop a Model of Care for its members with special needs to satisfy their health needs and improve their quality of life. 3

4 Dual Special Needs Plan (D-SNP) Definition: Health plan for people who are eligible to receive benefits from Medicare Parts A and B, and Medicaid. Medicare A + B D- SNP Medicaid MCS has a contract with Medicare and can offer Classicare Platino products to their dual elegible beneficiaries. 4

5 Model of Care (MOC) The MOC is a vital Quality Improvement tool and an integral component to ensure that the unique needs of each enrolled beneficiary are identified and addressed. MOCs provide the needed infrastructure to promote quality, care management and care coordination processes for SNPs members. The MCS Quality Department Is responsible for overseeing, monitoring, and evaluating actions related to MOC. 5

6 D-SNP Products at MCS 2017 MCS Classicare has three (3) SNP products: Product Name MCS Contract Number MCS Group Number 1. MCS Classicare Platino Ideal (Renewal 2017) H MCS Classicare Platino Progreso (Renewal 2017) H MCS Classicare Platino Ca$h (Renewal 2017) H As October 2016, the Platino products had a population of approximately 106,047 members. 6

7 Model de Care Elements MOC 1: Description of SNP Population MOC 2: Care Coordination MOC 3: Provider Network MOC 4: MOC Quality Measurement and Performance Improvement 7

8 MOC 1: Description of SNP Population A.Description of SNP Population Most relevant diagnostics: diabetes mellitus, hypertension and Metabolism of lipid disorder* 10% of the population did not visited their PCP* Membership > 65 years (48.04%)* Survey: CAHPS 2015: 29% answered about their mental health status as good 26% claimed to have never finished high school B. Description of the Most Vulnerable Population 80% live with family member* 43% its depend on a person * *Population profile data from 2014/2015 8

9 MOC 2: Care Coordination A. Staff Structure *Clinical staff (require credentials) and non clinical staff * Initial and annually MCS provided the MOC training to employees and contracted staff B. Health Risk Assessment C. Care Plan *CHRA - Initial - conducted within the first 90 days of enrollment date Annual conducted within the 12 month of the last CHRA E. Transition of Care *Planned *Unplanned D. Interdisciplinar y Care Team (ICT) MCS has two Interdisciplinary Care Team *Standard *Complex * Conducted based on identified needs in the HRA (CHRA) 9

10 Health Risk Evaluation CHRA The CHRA is a tool designed to gather all the elements that help to identify clinical and non clinical needs of our members, initially and annually. The CHRA is performed by the member s Primary Care Physician. Clinical Information Non-Clinical Information *Revised annually to comply with new regulations. 10

11 Health Risk Evaluation - CHRA Needs that are identified in the CHRA and determine health risk level Physical Health Risk Level Logic Cognitive Psychosocial Health Risk *Score CHRA Severe >= 65 Moderate > 20 a < 65 Low <= 20 *Each section of CHRA has a weigth assigned and the sum of each of them leads to a final score Mental Health Functional 11

12 MOC 2: Care Coordination Individual Care Plans The development of Care Plans is assigned to a team of interdisciplinary care according to the member health risk level identified in the CHRA. Interdisciplinary Care Team Standard Members Health Risk Level Low Individual Care Plan Members Health Risk Level Moderate Interdisciplinary Care Team Complex Care Management Unit Members Health Risk Level Severe (Most vulnerable population ) 12

13 The interventions and recommendations established in the care plans are based on the following criteria Preventive care by age and gender Woman <65 years >65 years Man <65 years >65 years Present Chronic conditions Cardiovascular Diabetes Respiratory disease Renal disease Artritis Osteoporosis Hepatitis C HIV/AIDS Depression Mood disorder Alzheimer Hypothyroidism Assessment of individual needs Performed by the case manager to establish specific interventions that address members health status. Low ICT Standard Moderate ICT Complex Severe Risk level 13

14 Sources of Information and Process to Perform Care Plans Initial source Referral to Care Management CHRA *HCC *RAPS Preliminary care plan based on age, gender and diagnosis Individual Health Risk Evaluation by Care Manager Updated Care Plan Health Risk Level Diagnosis reported Demoghaphic data Member High Risk Level (score > = 65) Member Health Risk Level : low and moderate Care plan based on age, gender and identified diagnosis *HCC (Hierarchy Condition Category) * RAPS (Risk Adjustment Processing System) 14

15 Individual Care Plan includes: Header Situation Member s name ID number PCP name Age and gender Chronic conditions Intervention Preventive self-care recommendations by age, gender and chronic conditions Support Intervention o MCS interventions to promote the member s health care PCP interventions o For the assessment and management of health member s 15

16 Communication Process and Care Plan Update Low and Moderate Severe Care Plan at least once a year. Care plan is modified if a new CHRA is reported and if changes at levels of risk and / or diagnostics are found. Care plan and letter are sent to the member and PCP. This information is included in the Care Management electronic tool (CCMS). The Care plan is available for ICT througth CCMS. Care plan is revised and discussed with the member as needed, and is send at least every 6 months, modified according to the member s health needs while in the program. Goals evaluates to be in compliance and interventions are registered in CCMS. A letter with the Care Plan is sent to the member and PCP. This information is included in the Care Management electronic tool (CCMS). The Care plan is available for ICT througth CCMS. 16

17 Efforts to promote interventions and recommendations of the Care Plan Members Primary Care Physician Individual Care Management interventions for severe health risk level Preventive care and chronic management conditions reminders Clinical Management warning letters Educational campaigns Educational material and self-care guide sent Management of chronic conditions workshops Health talks Cuídate Magazine Workout session through MCS Health Step by Step Delivery and discussion of quality measure report by PCP Clinical management warning letters Educational interventions with clinical accredited continuing education Educational campaigns Clinical care coordination call for severe health risk level 17

18 Interdisciplinary Care Team (ICT) The interdisciplinary care team provides the structure and processes to offer and coordinate services for the health care of our Special Needs Plan members of MCS, according to their health status and needs. Standard Member / caregiver PCP Care Manager - RN Social Worker Pharmacy Health Educator Mental Health Utilization Management Management Information *Complex Afiliado/cuidador Médico Primario Manejador de Cuidado - RN Gerente de Manejo de Cuidado - RN Directora de Manejo de Cuidado - RN Trabajadora Social Farmacia Salud mental *Ad hoc: Others: Specialist, Rehabilitative Therapy and others as needed. 18

19 Care Transition Planned Transition *Elective surgery *Skilled Nursing Facilities (SNF) or Home Health Agency (HHA) Admission. C. Experiencia de Cuidado del Afiliado D. Grupo Interdisciplinario Unplanned Transition *Emergency department visit that hospital admission involved Care Transition: Movement of a member from one healthcare scenario to another 19

20 Transition of Care MCS educates members during the care transition process in the following ways: o Care Transition Letter to the Member and PCP o 24/7 Medilínea o Educational Material for the Condition s Self-care (Cuídate Magazine, Preventive Reminders (Diabetes, Cardiovascular, etc.) o Phone calls 20

21 MOC 3: Provider Network A. Especialistas MCS has: Internal medicine Endocrinologist Cardiologist Mental Health, among others B. Guías Clínicas & Protocolo Transición de Cuidado MCS adopts, revises and shares clinical guidelines to support the PCP and member in the decision making of the appropriate medical care Care Transition *continuity of care C.Adiestramient o a la Red de Proveedores Initial y annual Participant providers Out-of-network providers seen members on a routine basis Delegated entities (FHC, among others) Example of clinical guidelines: asthma, cancer, diabetes, etc. 21

22 MOC 4: MOC Quality Measurement and Performance Improvement A. MOC Quality Performance Improvement Plan Data Source - CCMS, CHRA, PMHS *Involved leadership and other personnel on decision-making of internal quality performance processes B. Measurable Goals and health Outcomes for the MOC *Measures indicators *HEDIS *CAHPS *Operational reports E. Dissemination of SNP Quality Performance Related to the MOC D. Ongoing Performance Improvement Evaluation of the MOC MCS provides communication to: Boards of Directors Employee Provider, among others * Monitors and analyzes the quality indicators to identify opportunities for improvement C. Measuring Patient Experience of Care *Survey -CAHPS -HOS - Internal Survey (Members Satisfaction) 22

23 Important Information about the Provider 23

24 Role of the Primary Care Physician and Specialist Physician Participate in planning patient care. Provide the necessary medical care. Provide education of the health condition to the member and/or caregiver. Encourage patients prevention and healthy lifestyle. Encourage patients to participate in their care process (self care). 24

25 Role of the Primary Care Physician and Specialist Physician Participate in interdisciplinary team meetings: o Keep communication with the care manager, the interdisciplinary care team and/or caregiver and work together with the individual Care Plan. Provide access and integrate other physicians or providers within the patient care management, if necesary. Use the Clinical Practical Guidelines (CPG) adopted by MCS (available in Provinet). Revise and update the care plan and answer the member preferences and/or concerns. Ensure the continuity of care and/or services to the patient, and provide follow up to the treatment. 25

26 Role of Ancillary Services and Facilities Provide the necessary medical care. Incorporate the Primary Care Physician within the patient s healthcare. Report to the medical plan any identified barrier related to services access and/or transition process. Encourage patients to participate in their care process (self care). Provide the services on time. 26

27 GAP in Care Available through Provinet Website HEDIS Measure 27

28 Clinical Practical Guidelines Available thought MCS Website Example: Asthma, Cancer, etc. 28

29 MOC Training Available through Provinet Website Provinet Access : Communication : Category : MCS Classicare > Sub Category : D- SNP Modelo de Cuidado Informative Provinet Website: 29

30 MOC Training Available through Provinet Website 30

31 Care Management Program Referral Form Available in Provinet 31

32 Thank you for your commitment to improving the quality of life of our members! 32

33 Definitions HCC (Hierarchy Condition Category)- Classification system based on health status (diagnostic data) and demographic characteristics (such as age and sex) of a beneficiary to calculate risk scores. RAPS (Risk Adjustment Processing System) - Process that allows CMS grants to the health plan premium payment corresponding according to the health risk of the beneficiary. CAHPS (Consumer Assessment of Healthcare Providers and Systems ) - Survey that collects, evaluates and reports on the experience (perception) of the members in relation to services received from insurers and providers. HOS (Health Outcomes Survey ) - Surveys that gather valid and clinically significant data on patients mental and physical wellness. CCMS (CareEnhance Care Manager Software) - Application that provides clinical management information for our members. 33

34 References MCS SNPs 2016 Model of Care Description Medicare Managed Care Manual Quality Improvement Program Chapter 5 Section 20.2 Additional Quality Improvement Program Requirements for Special Needs Plans (SNPs) Model of Care (MOC) General SNP Model of Care (MOC) Summaries at CMS website: Care-Summaries.html 34

35 For any question, please contact: Please include your contact information Contact person/department Phone 35

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