Generations Advantage Focus DC (HMO SNP) Diabetes Care Special Needs Plan GENERAL MODEL OF CARE (MOC) TRAINING

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1 Generations Advantage Focus DC (HMO SNP) Diabetes Care Special Needs Plan GENERAL MODEL OF CARE (MOC) TRAINING

2 Through this training you will learn: What is a SNP? What is Martin s Point Generations Advantage Focus DC? What is the Focus DC Model of Care? Goals Interdisciplinary Care Team Provider Network Health Risk Assessments/Individualized Care Plans Communications Care Management Performance & Health Outcome Measurement

3 What is a Medicare Advantage SNP? A Special Needs Plan (SNP) is a type of coordinatedcare Medicare Advantage plan designed to provide targeted care and services to individuals with unique needs. Types of Special Needs Plans include: Dual-Eligible SNPs for individuals with Medicare and Medicaid Institutional SNPs for individuals living in institutions Chronic-Condition SNPs for individuals with specific conditions

4 What is Focus DC? Martin s Point Generations Advantage Focus DC is a Chronic-Condition Special Needs Plan designed for people who have been diagnosed with diabetes as a chronic or disabling condition. To be eligible for enrollment in the plan, an individual must: Live in Cumberland County, and Be Medicare eligible, and Have a physician s verification of their diabetes diagnosis as a chronic or disabling condition (Does not include individuals considered to be pre-diabetic.)

5 What is Focus DC? Focus DC augments core primary care services with disease management programs designed to improve patient health outcomes and reduce healthcare costs. The plan features: Coordinated care Smaller patient populations Close partnership between plan, members, and providers Individual care plans Specialized benefits Disease/Case management services

6 What is Focus DC? Working as an extension of primary care, Focus DC will help members understand their chronic condition, follow the treatment plans recommended by PCPs, take prescribed medications, and make healthy choices that improve the quality of their lives.

7 What is the Focus DC Model of Care? Members choose an in-network primary care provider who manages their care and referrals to in-network specialists and facilities. Preauthorization from Generations Advantage is required for some services such as inpatient hospital care.

8 What is the Focus DC Model of Care? Other special benefits include: $0 copays for many generic prescriptions at pharmacies with preferred cost-sharing $0 copay for lab work relating to diabetes $40 copays for preventive dental care through the Northeast Delta Dental (NEDD) network Free 24-hour nurse hotline Local customer service (phone or in-person)

9 What is the Focus DC Model of Care? Care Manager, nurse practitioner, and Member Services representative introduce member to new plan benefits and discuss individual health needs Lays foundation for targeted care Care Manager serves as the member s single point of contact for their care and helps coordinate the efforts of all members of a Care Team Care Manager guides member to ensure that care is received when needed

10 What is the Focus DC Model of Care? Coordinated care from a network of health care professionals who have expertise in diabetic care Includes PCP, specialists, health educators and coaches, behavior health experts, social supports, and more Member and Care Team develop a Care Plan with member s unique health needs and goals in mind Care Plan will help member stay on track to receive screenings and specialist care recommended by the American Diabetes Association

11 Focus DC Goals Improved patient experience, health outcomes, and cost of care for people living with diabetes Network of community support and resources for people living with diabetes Care Manager assigned to each member serves as the single point of contact for the member and Interdisciplinary Care Team (ICT) Improved access to care and specialized benefits Increase member engagement with their primary and specialty care providers Increased member and family involvement regarding end-oflife treatment preferences, living wills, advance directives, etc.

12 Interdisciplinary Care Team Focus DC uses an Interdisciplinary Care Team (ICT) approach to ensure patients receive the extra guidance, coordinated care, community resources, and specialized benefits they need to live healthier lives with diabetes. ICTs are coordinated by Focus DC Care Managers and include: Patients Primary care providers and staff Pharmacist and medical director Other team members as needed: Specialty providers such as endocrinologists and podiatrists Social workers and mental health providers Family members and community resource groups

13 Interdisciplinary Care Team Care Manager Welcome Visit/Health Risk Assessment Development of Individual Care Plan with member Determine whether a member home assessment is needed Motivational interviewing and self-management support Community Care Specialist Assessment of socioeconomic, social, and emotional needs Patient safety assessments Primary Care Providers, Specialists, and Staff Medical expertise, diabetes care, and communication with ICT Clinical Pharmacist Medical Therapy Management (MTM) Medical Director Supports the Care Manager, Community Care Specialist, and pharmacist Leads weekly case reviews, providing input as needed

14 Provider Network Primary Care Providers: Select PCPs in Cumberland County, Maine, chosen based on: Diabetic quality of care Diabetic health outcomes Diabetic expertise and experience Collaborative partnership Location/member access Specialty Providers and Facilities: Focus DC members enjoy access to the entire Generations Advantage network of specialists and facilities across Maine and New Hampshire.

15 Health Risk Assessment/Individual Care Plan A Focus DC Care Manager and nurse practitioner will conduct a Welcome Visit with each new member as they join the plan. With the member they will: Discuss plan benefits and individual health needs Conduct a Health Risk Assessment (HRA) Establish the relationship between member and ICT The Care Manager will share the results of this Welcome Visit with PCPs in the form of an Individual Care Plan for each Focus DC member on their patient panel. IMPORTANT! This Welcome Visit does not take the place of the Comprehensive Annual Physical Exams or Annual Wellness Exams that PCPs deliver to Focus DC patients each year.

16 Communications with PCPs: A dedicated Care Manager for each Focus DC patient on a PCP panel will serve as a single point of contact for you and your office staff. When a new Focus DC member selects a PCP, we will notify PCP in writing and share their Individual Care Plan. Acting as an extension of the primary care team, the Care Manager will check in periodically with Focus DC members, reinforce the importance of primary care, assess any barriers to care, offer diabetes self-management education, and connect them with community resources as appropriate.

17 Focus DC Goals Coordinated transitions of care: Post-discharge support Follow-up physician visits within seven days of hospitalization Documentation of post-discharge medication reconciliation Appropriate utilization of services: Reduced hospital admissions Reduced readmission rates Reduced emergency room visits

18 Care Management: What do we expect from PCP offices? Follow diabetes-care best practice (see DM Protocol addendum for more details) Conduct annual physicals, annual wellness visits Conduct complete and accurate diagnosis coding and documentation Review the care plan when sent and reach out if any concerns or questions

19 Communications: What do we expect from PCP offices? Most Focus DC member Individual Care Plans will not require a response, but some will. We expect timely replies, if requested. We ask Focus DC PCPs to share medical records upon request, notify us of any specialist referrals, social/ situational obstacles, or death of a patient. If we contact PCP offices with patient concerns or requests, we ask that PCP offices make best efforts to reply within hours, or as soon as possible for urgent care management requests.

20 Care Management: What can PCPs expect? Notification when your Focus DC patient has enrolled in our case management program Invitations to participate in case reviews with Interdisciplinary Care Teams as needed Care coordination support, as needed, for their Focus DC patients: Transitions of care Community resources Benefit optimization

21 Measurement and Metrics We analyze claims data, track any gaps in care, and communicate regularly with PCPs about patients who are Focus DC members. We use a variety of research and survey tools to measure health care quality, patient health outcomes, health care access, the patient experience, plan/provider satisfaction, and more. We track operational metrics to ensure we are fulfilling the process of the Model of Care.

22 Care Management Process Generations Advantage Member Services completes Welcome Call: Benefit Overview Schedules Welcome Visit with Generations Advantage nurse practitioner In order to capture member s clinical baseline Connects member with self-completed Health Risk Assessment, based on member preference In order for member to self-identify current health status, barriers to care, and personal goals

23 Care Management Process Generations Advantage nurse practitioner completes a clinical Welcome Visit: In-office or in-home visit Provides clinical foundation for Individual Care Plan Ensures we capture diagnosis codes appropriate to member s condition as required by CMS

24 Care Management Process Focus DC Care Manager completes Individual Care Plan with the member and/or caregiver Informed by past data (current Generations Advantage members), Generations Advantage NP Welcome Visit, and Health Risk Assessment Based on member s unique health needs and goals Care Manager identifies member health risk Determines case review time frame

25 Care Management Process Care Manager initiates case reviews with Interdisciplinary Care Team Minimum: annually for each member Post-discharge ICT meets weekly Care Manager tracks and coordinates care with PCP office and member

26 Questions For further information, please contact: Susan Lyons Health Management Clinical Program Manager Martin s Point Health Care susan.lyons@martinspoint.org