CareMore Special Needs Plans Model of Care. Annual Evaluation 2015 Performance
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1 CareMore Special Needs Plans Model of Care Annual Evaluation 2015 Performance
2 The Special Needs Plans (SNPs) Medicare SNPs are a type of Medicare Advantage Plan (like an HMO or PPO). Medicare SNPs limit membership to people with specific diseases or characteristics, and tailor their benefits, provider choices, and drug formularies to best meet the specific needs of the groups they serve. www. medicare.gov 2
3 The Special Needs Plans (SNPs) Medicare limits SNPs to: 1) people who live in certain institutions (like a nursing home) or who require nursing care at home ( I-SNP ) 2) people who are eligible for both Medicare and Medicaid ( D-SNP ) 3) people who have specific chronic or disabling conditions ( C-SNP ) 3
4 CareMore offers 6 Special Needs Plans CareMore Touch I-SNP for people who live in certain institutions (like a nursing home) or who require nursing care at home CareMore Connect D-SNP for people who are eligible for both Medicare and Medicaid CareMore Breathe C-SNP for people who have specific chronic lung conditions CareMore Diabetes C-SNP for people who have diabetes CareMore ESRD C-SNP for people who have End-Stage Renal Disease CareMore Heart C-SNP for people who have specific chronic cardiovascular conditions 4
5 The SNP Model of Care (MOC) CareMore has a formal Model of Care which describes the care and resources offered by the SNPs. The MOC also establishes performance goals to ensure the SNPs provide high-quality care to members. Every year, we evaluate how the SNPs meet the Model of Care and report this information to members, healthcare providers, and health plan teams. 5
6 Special Need Plans Model of Care Care Coordination Health Risk Assessments Individualized Care Plan Interdisciplinary Care Team Care Transitions/Case Management Referrals
7 Health Risk Assessment (HRA) SNP members should complete a Health Risk Assessment (HRA) when they join the plan and then every year afterward CareMore Care Centers offer special HRA visits* Healthy Start visit for new SNP members, first 90 days of enrollment Healthy Journey visit for existing SNP members at least annually, or as health care status changes *I-SNP members receive HRAs unique to the CareMore Touch program HRAs address medical, cognitive, functional, psychosocial and mental health of each SNP member The HRA Tool is integrated into our Electronic Health Records (EHR) systems and used to develop the Individualized Care Plan (ICP) 7
8 Individual Care Plan (ICP) The Individualized Care Plan (ICP) is created based on needs identified in the HRA. Each member is involved in developing his or her own care plan and goals. The ICP considers personal preferences It includes self-management plans and goals It identifies potential barriers and progress It is reviewed and/or updated at least annually, or as health care status changes It is shared with the Interdisciplinary Care Team (ICT), which includes healthcare providers, the member, plus caregivers and others needed to ensure comprehensive coordination of care 8
9 Interdisciplinary Care Team (ICT) At the highest level, the Interdisciplinary Care Team (ICT) evaluates the needs of members based on their risk levels and severity of their healthcare needs. This team includes: The member and caregiver(s) Primary Care Physicians, Extensivist Physicians, and Specialists Nurse Practitioners, Behavioral Health providers, and Registered Dieticians Case Managers and Social Workers and others needed to ensure comprehensive coordination of care Communication within the ICT includes telephonic and/or face-to-face meetings and electronic data transfer record keeping 9
10 Care Transitions A Care Transition refers to the movement of a patient between one healthcare setting to another. This could be from doctor s office to hospital, or from hospital to skilled nursing facility, but patients are at their most vulnerable when transitioning from hospital to home. A main objective of the SNP Model of Care is to assist the member through all care transitions, with a special focus on hospital stay and post-hospital follow up care: Planning and preparing for care transitions Ensuring care after transitions are completed Communication with and coordination of treating providers This is accomplished by: Interdisciplinary care transition protocols Updating, communication, and implementing ICPs Providing clear communication and needed education to members and caregivers Periodic re-evaluation of progress or decline in health status 10
11 Care Transitions When the health status of a SNP member changes, the ICT is mobilized to provide the unique care that is needed Extensivist Physicians visit patients in the hospital or skilled nursing facility Primary Care Providers are notified/consulted on recommended plan of care Specialty Providers are consulted as needed Case Managers provide outreach and discharge planning support Schedule post-hospital follow up visits with Extensivists Continue communication with member based on post-discharge risk protocols Coordinate with Extensivist and Advance Practice Clinician to update the ICP with communication back to the Primary Care Provider 11
12 Case Management The Case Management Department is designed to ensure members receive personalized care coordination across the entire delivery of care model and is focused on the clinical, behavioral and social needs of CareMore members Complex Case Management Social Worker Services Palliative Care Referring to other services as needed Behavioral Health CareMore Care Center programs Long-Term Services and Supports (LTSS) if available Home Health Hospice 12
13 Special Need Plans Model of Care 2015 Model of Care Performance Evaluation
14 2015 vs Goal Measured by Status Improve Access Improving access to affordable medical, mental health and social services Improve Coordination of Care Improving coordination of care Improving transitions of care across health care settings Improve Utilization and Health Outcomes Improve appropriate utilization of preventive health services Identifying baselines and benchmarks for marked patient health outcomes Access and Availability Studies Program Participation SNP Benefits review HRA and ICP Completion Readmissions Post Discharge Follow-up within 30 days SNP healthcare quality measures (4-star or higher) Member Satisfaction Surveys Met Goals for All Measures 60% 17% % 13.9% <70% 90% 89% Needs Improvement Met Goal Needs Improvement Met Goal Met Goal 14
15 2016 Initiatives Based on review of 2015 performance, the CareMore advisory committee recommends the following course of action for 2016: Improve Access & Affordability Initiatives Increase CareMore Care Center disease management program participation Improve Coordination of Care Increase rate of Kept Appointments for Post-Hospital Follow-Up Enhance telephonic HRAs and ICPs for member convenience Improve Utilization and Health Care Outcomes Continue outreach for preventive screenings and quality healthcare measures Introduce real-time patient satisfaction surveys in the CareMore Care Centers 15
16 Special Needs Plans Model of Care Questions and Inquiries can be submitted to: CareMore Quality Management 16
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