SPECIAL NEEDS PLANS (SNP) Model of Care Training

Transcription

1 SPECIAL NEEDS PLANS (SNP) Model of Care Training 1

2 OBJECTIVES SNP Background Types of SNPS ATRIO Model of Care Reference Material 2

3 SNP BACKGROUND The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) authorized the creation of a type of Medicare Advantage (MA) plan referred to as a Special Needs Plan (SNP), to address the unique needs of certain Medicare populations. SNPs have been reauthorized several times since their establishment. The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) and the Patient Protection and Affordable Care Act (PPACA effective January 1, 2012) both contain provisions reauthorizing and modifying SNPs. 3

4 TYPES OF SNPS D-SNP (Dual Eligible) For individuals who qualify for both Medicare Part A and Part B and full Medicaid benefits I-SNP (Institutionalized) For individuals residing in nursing facilities or institutions C-SNP (Chronic Condition) For individuals with severe or disabling chronic conditions 4

5 ATRIO & D-SNP D-SNP (dual-enrollment) is the only SNP ATRIO currently offers. All ATRIO s SNP beneficiaries are classified as D-SNPs. In addition to meeting all the requirements of other MA plans, all SNPs, including D-SNPs, are required by the Centers of Medicare and Medicaid Services (CMS) -- the agency in the Department of Health and Human Services (HHS) that administers Medicare and oversees Medicaid -- to provide specialized services targeted to the needs of their beneficiaries, including a health risk assessment, individualized care plans with interdisciplinary care team for each enrolled beneficiary as well as transition of care plans when needed. 5

6 MODEL OF CARE (MOC) CMS requires D-SNPs to develop a MOC that describes their approach to caring for their target population. The SNP MOC is a working framework or our promise indicating how the SNP proposes to coordinate the care of SNP enrollees. REQUIRED TRAINING CMS requires all employed and contracted staff, who provide indirect and direct care coordination services to SNP members, to complete an initial SNP MOC training and annually thereafter. ATRIO delegates this requirement to each SAC who will provide the initial and annual training for all employed and contracted staff and maintain the documentation of that training as required. For more information please refer to ATRIO s SNP MOC Policy & Procedure 6

7 SNP MOC Contents MOC 1: Description of SNP Population Element A: Description of Overall SNP Population Element B: Subpopulation Most Vulnerable Beneficiaries MOC 2: Care Coordination Element A: SNP Staff Structure Element B: Health Risk Assessment Tool (HRAT) Element C: Individualized Care Plan (ICP) Element D: Interdisciplinary Care Team (ICT) Element E: Care Transitions Protocols MOC 3: Provider Network Element A: Specialized Expertise Element B: Use of Clinical Practice Guidelines and Care Transition Protocols Element C: MOC Training for the Provider Network MOC 4: MOC Quality Measurement and Performance Improvement Element A: MOC Quality Performance Improvement Plan Element B: Measurable Goals and Health Outcomes for the MOC Element C: MOC Training for the Provider Network Element D: Ongoing Performance Evaluation of the MOC Element E: Dissemination of SNP Quality Performance Related to the MOC 7

8 MOC 1: Description of SNP Population A comprehensive description of ATRIO s SNP-specific population that addresses the full continuum of care for current and potential SNP beneficiaries and describes the specially tailored services for these most vulnerable members. The description includes social, cognitive, environmental, living conditions and medical and health conditions including co-morbidities of ATRIO s SNP population. 8

9 MOC 1: Description of SNP Population Demographic Summary of SNP Population SNP Gender 41% 59% F= M= 86->100= 7% 64-85= 46% SNP Age Distribution 0-50 = 23% 51-63= 24% 0-50 = 51-63= 64-85= 86->100= SNP Low Income Subsidy 51% 2% 47% 1= 2= 3= 5% 2% SNP Languages 34% 59% English= Russian= Spanish= Other= Asian= 2% Hispanic= 6% African American= 1% Other= 4% SNP Ethnicity Caucasia n= 85% Native American= 2% 9

10 MOC 1: Description of SNP Population MOC 1 details the specifically tailored services ATRIO provides to its most vulnerable members and established relationships with partners in the community to provide needed resources. Services and Programs TOC program (Transitions of Care) CCM program (Complex Case Management) ICT activities (Interdisciplinary Care Team) CHE programs (Comprehensive Home Evaluations) QIPs (Quality Improvement Programs) CCIP (Chronic Care Improvement Program) ENCC (Exceptional Needs Care Coordination) Medication Therapy Management Overutilization of Opioids Pharmaceutical Program CCSMP/Living Health Program (Chronic Care Self-Management Program) All of ATRIO s services and programs are reviewed internally and by the QA Committee throughout the year in order to determine best practices, effectiveness and process improvements. 10

11 MOC 1: Description of SNP Population Community Partnerships OHP (Oregon Health Plan) including the SAC CCOs Clinical Advisory Panel Service area Behavioral, Mental and Addiction Health Organizations DHS (Department of Health & Human Services) including NWSDS (Northwest Senior and Disabled Services) Home Health Care Agencies DME Companies Service area Pharmacies Service area Provider practices Palliative and Hospice Care services Service area Hospitals Transportation Services Various not-for-profits; churches, food banks and homeless shelters Adult Foster Homes, Skilled Nursing Facilities, Assisted Living Facilities & Rehabilitation Facilities Mental Health Inpatient and Outpatient Facilities Specialty Pain Clinics Meals on Wheels For more detailed description of these programs and partnerships please refer to ATRIO s SNP MOC; MOC 1; Element B. 11

12 MOC 2: Care Coordination Care Coordination helps ensure that SNP beneficiaries health care needs, preference for health services and information sharing across the health care staff and facilities are met over time. Care coordination maximizes the use of effective, efficient, safe, high-quality patient services that ultimately lead to improved health care outcomes. Utilizing a variety of sources, ATRIO prioritizes care coordination and case management activities for our high risk SNP members. All care coordination and case management activities are documentation in TCS Acuity, ATRIO s designated case management software. 12

13 MOC 2: Care Coordination Element A outlines SNP Staff Structure. With over 5,400 SNP members it takes organization-wide effort to coordinate care services for our SNP members. 13

14 MOC 2: Care Coordination Element B addresses the HRAT (Health Risk Assessment Tool). The HRA is a comprehensive questionnaire used by the Plan to identify the specialized needs of its beneficiaries and to coordinate care that reflects the member s personal preferences. The HRA questionnaire assesses medical, psychosocial, cognitive, and functional needs as well as the SNP member s medical and mental health history. Per CMS requirements, ATRIO mails each SNP member an HRA within 90 days of enrollment and annually thereafter. Follow up letters and phone calls are placed in the event an HRA has not been received. HRA responses are uploaded to ATRIO case management software for reference by case management. Referrals are made as needed. SNP members who are unable to complete the written form of the HRA are encourage to call Customer Service and request HRA completion assistance over the phone with one of our NCMs. 14

15 MOC 2: Care Coordination Element C addresses the Individualized Care Plans (ICP). ATRIO has adopted the CMS definition of a care plan meaning a set of information about the patient that facilitates communication, collaboration and continuity of care across settings. The ICPs are generated by an assigned NCM using SNP member specific information from a variety of sources including but not limited to: claims, the HRA, CHE*, medical records and information gathered by the NCM and other ICT members from the SNP beneficiary and/or caregiver(s). *Home visits in the form of Comprehensive Home Evaluations (CHEs) are also conducted on a regular basis to collect information on most vulnerable SNP members. 15

16 MOC 2: Care Coordination ATRIO delegates the responsibility of development and management of the ICP to the SAC assigned NCM. ICPs are created and managed within TCS Acuity, ATRIO s designated case management software. Components of an ICP SNP member demographic information including contact information Primary Care Provider & contact information A list of other providers the members has seen in the past 12 months Current health insurance coverage and eligibility information A list of medications A list of medication adherence issues A list of care diagnoses A list of gap care A Case Management note from the assigned NCM A list of active goals and associated interventions A list of ICT members 16

17 MOC 2: Care Coordination Element D addresses Interdisciplinary Care Teams (ICT). ATRIO has adopted the CMS definition of an Interdisciplinary Care Team to refer to a team of professionals from multiple disciplines who work together to coordinated and facilitate patient focused care. ATRIO delegates this process to its Service Area Contractors (SAC). Each SAC is responsible to follow the specific ATRIO ICT policy and procedure (located within the SNP CM Policy and Procedure) as well as the framework outlined in the SNP MOC. SNP members are assigned to a NCM within their service area who forms the member s ICT based on the profession ICTs will at a minimum and whenever feasible include the assigned NCM, the SNP member and/or primary caregiver and the member s PCP. 17

18 MOC 2: Care Coordination 18

19 MOC 2: Care Coordination Element E addresses Care Transitions Protocols. ATRIO has adopted the following CMS definitions used to explain care transitions: Healthcare settings The provider from whom or setting where a member receives health care and healthrelated services. In any setting, a designated practitioner has ongoing responsibility for a member s medical care. Transition Movement of a member from one care setting to another as the member s health status changes. For example, moving from home to a hospital as the result of an exacerbation of a chronic condition or moving from the hospital to a rehabilitation facility after surgery. Transitions process The period of identification of a member who is at risk for a care transition through completion of a transition. This process includes planning and preparation for transitions and the follow-up care after transitions are completed. 19

20 MOC 2: Care Coordination ATRIO makes special effort to coordinate care when SNP members move from one health care setting to another, such as when they are discharged from a hospital. Without coordination, such transitions often result in fragmented and unsafe care for the older or disabled and particularly vulnerable SNP beneficiary. ATRIO s Transitions of Care program is designed with the intent to minimize risks associated with health care transitions. ATRIO delegates the responsibility of coordination of the care transitions processes to the SAC assigned NCMs. Each SAC is responsible to follow the specific ATRIO TOC policy and procedure (located within the SNP CM Policy and Procedure) as well as the framework outlined in the SNP MOC. The case management software serves as the central location for the documentation of care management and care coordination activities including the care transitions processes. 20

21 MOC 3: Provider Network The SNP provider network is a network of health care providers who are contracted to provide health care services to SNP beneficiaries. SNPs must ensure that their MOC identifies, fully describes and implements the following element for their SNP provider network: Specialized Expertise, Use of Clinical Practice Guidelines and Care Transitions Protocols and MOC Training for the Provider Network. ATRIO has established a vast network of providers and healthcare facilities allowing the Plan to provide exceptional access and care services to the often vulnerable SNP beneficiaries. ATRIO regards the primary care provider (PCP) as the expert in determining the health care needs of the SNP beneficiary. Each SNP member is required to have an identified PCP and our SAC NCMs, Customer Service Representatives and Provider Relations staff make special effort to match SNP members with a PCP they can be most aligned and satisfied with. 21

22 MOC 3: Provider Network In addition to our extensive network of primary care providers ATRIO has established an equally robust network of specialty and ancillary care providers for our SNP members. Medical Specialists Allergy & Immunology, Anesthesiology, Audiology, Cardiology, Chiropractic, Dermatology, Dietary, Endocrinology, Gastroenterology, Gerontology, Gynecology, Infectious Disease, Nephrology, Neurology, Obstetrics/Gynecology, Oncology, Ophthalmology, Oral Surgeon, Orthopedics, Otolaryngology, Pain Management, Podiatry, Psychiatry, Pulmonology, Rheumatology, and Urology Behavioral & Mental Health Clinical Psychologists & Licensed Clinical Social Workers Nursing professionals Nurse Practitioners Allied Health Professionals Pharmacies, Physical Therapists, Occupational Therapists, Speech Therapists, Pathology, Radiology Specialists Facilities Inpatient, Outpatient, Rehabilitative, Long Term Care, Psychiatric, Laboratory, Radiology/Imaging, Dialysis, Home Health, Urgent Care, Durable Medical Equipment Supplier 22

23 MOC 4: MOC Quality Measurement and Performance Improvement The goal of performance improvement and quality measurement is to improve the SNP s ability to deliver high-quality health care services and benefits to its SNP beneficiaries. Plan leadership, managers and governing bodies of the SNP organization must have a comprehensive quality improvement program in place to measure its current level of performance and determine if organizational systems and processes must be modified, based on performance results. 23

24 MOC 4: MOC Quality Measurement and Performance Improvement ATRIO has a quality improvement process by which various data sets collected from multiple sources are used to evaluate, measure, stratify and report on the Plan s Full- Dual Special Needs Plan Model of Care. The Quality Assurance Committee with authority from the Board of Directors is responsible for monitoring and evaluating the SNP MOC effectiveness. 24

25 MOC 4: MOC Quality Measurement and Performance Improvement The QA Committee Recommends outcomes to be monitored and establish benchmarks for ongoing monitoring and oversight of the SNP MOC. Evaluates the timeliness and response rate of the HRAs for SNP beneficiaries participation in the creation/management of individualized care plans. Annually evaluates the associated HEDIS, CAHPS and HOS data results Assists in the identification of the most vulnerable SNP beneficiaries Evaluates the Plan s ability to effectively communicate the results and effectiveness of the MOC to all stakeholders and recommend enhanced training if need be. Recommends improvements to the SNP MOC and the evaluation process 25

26 MOC 4: MOC Quality Measurement and Performance Improvement ATRIO s MOC measurable goals and health outcomes revolve around the areas of access to care services, affordability, coordination of care, care transitions and utilization of services for preventative health and chronic conditions. The following are ATRIO s current measurable goals 26

27 MOC 4: MOC Quality Measurement and Performance Improvement Measurable Goals ATRIO will achieve a score of 87% (est. 5 star level) on annual CAHPS results for the following questions: Ease of getting an appointment with a specialist Getting care, tests, or treatment necessary STAR Ratings Measures ATRIO will achieve a 99% (est. 5 Star level) for the MPF (Medicare Pharmacy Finder) price accuracy measure. ATRIO will achieve a score of 87% (est. 5 star level) on annual CAHPS results for the following questions: Doctor had medical records or other information about your care Doctor talked about prescription medicines Got help managing care Doctor informed and up-to-date about specialty care ATRIO will achieve a 80% return rate (est. 5 star level) for the HRA (Health Risk Assessment) ATRIO will achieve <9% (est. 4 star level) for Plan All-Cause Readmissions (readmissions to a hospital within 30 days of being discharged) ATRIO will achieve 80% of diabetic SNP members whose most recent HbA1c level is less than or equal to 9% (est. 4 star level) ATRIO will achieve a 60% (est. 4 star level) for Osteoporosis Management. 27

28 MOC 4: MOC Quality Measurement and Performance Improvement ATRIO operates under a continual process of quality improvement for all of our programs, especially those directly involving our most vulnerable SNP members. ATRIO s QA Committee and SNP Leadership prioritize mechanisms of improvements to the SNP MOC and respond to lessons learned and implement those improvements in as timely a manner as possible with the end goal of assisting our SNP members in achieving the highest level of quality care. 28

29 TRAINING REVIEW ATRIO offers D-SNP plans to address the unique needs of Medicare beneficiaries. Per CMS we ve developed a SNP Model of Care (MOC) that all employed and contracted staff must be trained on upon hire and annually. SNP MOC Outlines The unique needs of ATRIO s SNP population How ATRIO coordinates care to meet these needs The established ATRIO provider network Goals to improve quality and performance 29

30 FOR YOUR REFERENCE To obtain a full copy of ATRIO s SNP MOC and ask any questions please contact ATRIO Medical Management by calling ATRIO Customer Service at Any suspected issues of non-compliance or fraud, waste and abuse should be reported immediately to ATRIO Compliance at compliance@atriohp.com or ATTENTION PROVIDERS - Please proceed to the following slide for your training attestation. After printing your attestation, please the signed form to: atrio_attestation@atriohp.com Please keep in mind this is an annual training requirement. Thank you for the care you provide ATRIO SNP members! 30

31 2018 SNP MOC Training Provider Attestation I,, hereby attest that I have reviewed ATRIO Health Plan s Model of Care training which completes the annual requirement. I understand the Model of Care for our SNP members and my role in improving health outcomes for our most vulnerable population. I also understand this is an annual training required of me by the Centers for Medicare and Medicaid Services (CMS) for all Medicare Advantage Special Needs Plan contracted providers. Printed Clinic/Practice Name Printed Provider Name Signature Date To obtain a full copy of ATRIO s SNP MOC and ask any questions please contact ATRIO Medical Management by contacting ATRIO Customer Service at Any suspected issues of non-compliance or fraud, waste and abuse should be reported immediately to ATRIO Compliance at compliance@atriohp.com or Please return signed attestations to: atrio_attestation@atriohp.com Please retain for your records for proof of training upon request.