SPECIAL NEEDS PLAN (SNP) MODEL OF CARE TRAINING February 2016
T gain understanding and cmprehensin f EmblemHealth's Special Needs Plans (SNPs) T describe the prduct fferings prvided t EmblemHealth SNP members T gain understanding and cmprehensin f the Elements f the SNP Mdel f Care At the end f this training, yu will be able t describe the best practices fr the SNP Mdel f Care
Descriptin f the SNP ppulatin Care Crdinatin SNP Prvider Netwrk Quality Measurement and Perfrmance Imprvement
THE HISTORY OF SPECIAL NEEDS PLANS AT EMBLEMHEALTH Past Chrnic Care (diabetes) SNP n lnger ffered Several dual eligible SNPs Managed Lng Term Care (MLTC) Plan [Medicaid Advantage Plus (MAP)] n lnger ffered Fully Integrated Dual Advantage (FIDA) n lnger ffered Present EmblemHealth Dual Eligible HMO SNP EmblemHealth Dual Eligible PPO SNP
MEMBERS ELIGIBLE FOR MEDICAID EmblemHealth has tw Special Needs Plans in which enrllment is limited t beneficiaries wh are eligible fr Medicare and any level f Medicaid. These plans are: EmblemHealth HMO SNP (als knwn as the HIP SNP) EmblemHealth PPO SNP (als knwn as the GHI SNP) Member Benefits: These SNPs ffer all f the required Medicare benefits and include reduced member csts fr medical care and prescriptin drugs. Medicaid fee fr service may prvide additinal benefits if the member is eligible.
EMBLEMHEALTH SNP PLAN OFFERINGS HMO SNP Dual Plan PPO SNP Dual Plan
GOALS FOR OUR MEMBERS Imprve and Assure the Members Receipt Of the Fllwing: 1. Access t affrdable care and medical, mental health, scial and preventive health services 2. Crdinated care thrugh an identified pint f cntact 3. Transitin f care acrss health care settings and practitiners 4. Apprpriate services 5. Cst-effective services 6. Beneficiary health utcmes
SPECIAL NEEDS PLAN MODEL OF CARE OVERSIGHT CRITERIA The Centers fr Medicare & Medicaid Services (CMS) regulates all f the EmblemHealth SNPs. The SNP Mdel f Care review and apprval prcess ccurs initially and then peridically. SNP Plan Mdels f Care are scred using a CMS-apprved Reviewer Guide that identifies the types f evidence required fr each Element.
SPECIAL NEEDS PLAN MODEL OF CARE ELEMENTS Element 1: Descriptin f the SNP Ppulatin A. Overall SNP Ppulatin B. Sub-Ppulatin: Mst Vulnerable Beneficiaries Element 2: Care Crdinatin A. SNP Staff Structure B. Health Risk Assessment Tl C. Individualized Care Plan (ICP) D. Interdisciplinary Care Team (ICT) E. Care Transitins Prtcl
SPECIAL NEEDS PLAN MODEL OF CARE ELEMENTS CONTINUED Element 3: SNP Prvider Netwrk A. Specialized Expertise B. Use f Clinical Practice Guidelines and Transitin Prtcls C. MOC Training fr the Prvider Netwrk Element 4: Quality Measurement and Perfrmance Imprvement A. MOC Quality Perfrmance Imprvement Plan B. Measurable Gals and Health Outcmes C. Measuring Patience Experience f Care (SNP measurement f satisfactin) D. Onging Perfrmance Imprvement Evaluatin E. Disseminatin f SNP Quality Perfrmance
SNP MODEL OF CARE ELEMENT 1 SNP TARGET POPULATION Often because f educatinal and ecnmic factrs, this ppulatin des nt successfully navigate the healthcare delivery system and seeks care in emergency rms rather than having regularly scheduled preventive care visits Due t financial cnsideratins, eligible members ften d nt have cell phnes r hme telephnes, which can make it difficult t reach them t crdinate care and help them t manage their benefits Based n incme and educatin, these members may have pr nutritinal status and have issues with besity and high bld pressure, which can set the stage fr diabetes, heart disease and strke In additin, cultural cnsideratins, such as prevalence f smking in certain ppulatins, are als a factr
SNP MODEL OF CARE ELEMENT 2 CARE COORDINATION SNP Staff Structure Health Risk Assessment Tl Individualized Care Plan (ICP) Interdisciplinary Care Team (ICT) Care Transitins Prtcl
ELEMENT 2 STAFF STRUCTURE AND CARE MANAGEMENT ROLES The Staff Structure and Care Management Rles Sectin verviews the rles and respnsibilities f specific emplyed r cntracted staff wh perfrm clinical, administrative and versight functins. Sme f the clearly defined rles include: Pharmacists t review fr medicatin trends Utilizatin management supprt staff cmplete the necessary dcumentatin as member's transitin frm ne treatment setting t anther Case management clinical staff (Nurses and Scial Wrkers) prvide utreach t members t facilitate discharge and ther resurces as needed
ELEMENT 2 - HEALTH RISK ASSESSMENT (HRA) The HRAs are issued t all new SNP members within 90 days f their enrllment and then issued t all SNP members n an annual basis ging frward There are several utreach attempts made t btain the member's respnses They may be sent pstcards, an additinal survey r be part f a call campaign Once the respnses have been received, the answers are reviewed using an internally develped stratificatin guide The stratificatin guide assists in determining where the member shuld be referred internally fr further utreach, evaluatin and develpment f an individualized care plan r if they need the additinal assistance f ne f EmblemHealth's delegated entities Reprting is designed t identify members "at risk," members with selected cnditins, diseases r services, and members needing r requesting cnditin specific services that EmblemHealth ffer
ELEMENT 2 - HEALTH RISK ASSESSMENT HRA mailings and respnse reprting is cmpleted mnthly and respnses are referred electrnically t internal and external departments and prgrams t launch utreach effrts. Departments and Prgrams Such As: Utilizatin Management Case Management Disease Management Behaviral Health Custmer Service Smking Cessatin Prgrams These prgrams are multidisciplinary, cntinuum-based apprach t health care delivery that practively identifies members with, r at risk fr chrnic medical cnditin. It als supprts the dctr-member relatinship and plan f care, emphasizes the preventin and exacerbatin and cmplicatins using cst effective, evidence based practice clinical guidelines and member empwerment strategies such as selfmanagement.
ELEMENT 2 - HEALTH RISK ASSESSMENT Cmpleted HRAs prvide a methd fr the Plan t evaluate clinical, humanistic and ecnmic utcmes with the gal f imprving the verall health f ur member Thrugh educatin supprt and telephnic health caching, the SNP member is expected t shw an imprvement in treatment adherence and the subsequent reductin in inapprpriate and/r unnecessary medical utilizatin, r an increase in necessary medical utilizatin HRA prgram referrals result in an imprved quality f life, perids f imprved willingness fr members living with chrnic diseases, cnditins, while addressing quality f life issues
ELEMENT 2 INDIVIDUALIZED CARE PLANS The Individualized Care Plan (ICP) is the cmprehensive care planning dcument which is custmized t speak t the needs f the member A plan f care is the written dcumentatin f the case management prcess used t slve ne r mre f a member s prblems The ICP develpment begins when prblems are identified This prblem identificatin can begin during the administratin f the HRA, during interactins with the members and /r during the telephnic assessment f the member Additinally, prblems can be nted frm indirect surces when viewing the patient prfiler, reviewing member's claims fr their utilizatin patterns, evaluating the member s lab results r speaking with the primary care prvider The patient prfiler is a system which pulls tgether a members health data (such as lab, claims and pharmacy infrmatin), s that the case manager can get a current snap sht f the members health situatin
ELEMENT 2 INDIVIDUALIZED CARE PLANS The Individualized Care Plan (ICP) is a plan f care which flws frm each member s unique list f diagnses and is rganized by the individual's specific needs and includes the member s selfmanagement gals and bjectives. It shuld include bth lng and shrt term gals, which shuld be priritized based n the member's input The dcumentatin shuld als identify any barriers t the member being able t meet the gals and the ICP shuld be based upn identifiable physical, functinal, psychscial, behaviral, envirnmental, residential, family dynamics and supprt, spiritual, and cultural prblems It fcuses n actins which are designed t slve r minimize the existing prblem and incrprates the member s healthcare preferences It is a prduct f a deliberate systematic prcess which includes a descriptin f services specifically tailred t the members needs which relates t the future and prduces a desired utcme r change in the client's cnditin In rder t get the member t a state f reslutin f the identified prblems, the gals and bjectives are reviewed and evaluated peridically t see if they are met r nt met, r if the member wishes t cntinue t wrk n that gal If the ICP gals are nt met, the nurse case manager reviews the gals with the member, caregiver, the member s health care prvider t determine likely barriers, and develps apprpriate alternative actins The ICP shuld be discussed with the member during each utreach, and a written cpy shuld be sent t the member and prvider each time it is adjusted
ELEMENT 2 INTERDISCIPLINARY CARE TEAM The Interdisciplinary Care Team (ICT) is a multidisciplinary team (plan medical directr, nurses, scial wrkers, pharmacist, nutritinist etc.) designed t ensure apprpriate versight alng with frnt-line management f the prcesses and staff wh care fr SNP members This team apprach is member-centric and prvides access t care The member's electrnic medical recrd (EMR) shuld include written dcumentatin f the wh is part f their ICT, inclusive f their rles and respnsibilities The ICT shuld als include the members Primary Care Physician (PCP), any specialists, and the member r their representative
INTERDISCIPLINARY CARE TEAM EH ICT Team Member EH Behaviral Case Manager EH ICT Team Member EH Medical Directr EH ICT Team Member EH Scial Wrker Member Prvider EH Lead RN Case Manager EH ICT Team Member EH Pharmacist EH ICT Team Member EH Prvider Relatins Team EH ICT Team Member EH Ancillary Nnclinical supprt Team
ELEMENT 2 CARE TRANSITIONS PROTOCOL The rganizatin fllws Cleman s mdel that defines transitinal care as a set f actins designed t ensure the crdinatin and cntinuity f health care as patients transfer between different lcatins r different levels f care within the same lcatin Representative lcatins include (but are nt limited t) hspitals, sub-acute and pstacute nursing facilities, the patient's hme, primary and specialty care ffices, and lng-term care facilities Transitinal care is based n a cmprehensive plan f care and the availability f health care practitiners wh are well-trained in chrnic care and have current infrmatin abut the patient's gals, preferences, and clinical status It includes lgistical arrangements, educatin f the patient and family, and crdinatin amng the health prfessinals invlved in the transitin Transitinal care, which encmpasses bth the sending and the receiving aspects f the transfer, is essential fr persns with cmplex care needs
ELEMENT 2 CARE TRANSITIONS PROTOCOL Fr planned transitins frm the member s usual care setting t the hspital and transitins frm the hspital t the next care setting, EH identifies, via reprting mechanisms, that these planned transitins are ging t ccur The Care Manager utreaches t the member t determine if changes t the ICP are required based n the member s needs after the transitin Fr planned and unplanned transitins frm the member s usual care setting t the hspital and transitins frm the hspital t the next setting, EH facilitates sharing f the sending setting s plan f care with the receiving setting within ne business day f ntificatin f the transitin When a member experiences a planned r unplanned transitin frm any setting t any ther setting the member s usual practitiner is ntified f the transitin within 7 business days frm the time f ntificatin f the transitin
ELEMENT 2 CARE TRANSITIONS PROTOCOL Case Management care transitins prtcl fr Special Needs Prgrams (SNP) is administered in alignment with EmblemHealth s SNP Mdel f Care (SNP MOC) Special effrt is made t crdinate care when SNP members mve frm ne setting t anther, such as when they are discharged frm a hspital, t reduce risk f pr quality care, risks t patient safety and t maximize health utcmes Utilizing a multidisciplinary team apprach t supprt SNP member s medical, behaviral health, pharmacy, scial and financial needs, case managers wrk with the member, prvider, and cmmunity delivery systems t crdinate care and services Outreach is perfrmed t members newly discharged frm the hspital t ensure they understand their discharge plan, t arrange fr needed pst discharge services (such as hmecare, durable medical equipment, transprtatin, etc.) and t educate beneficiaries n self management techniques Individualized care plans (ICP) are frmulated with the SNP member s input fllwing an assessment and cntains, but is nt limited t the fllwing cmpnents: Member self management gals and bjectives; the member s persnal healthcare preferences; services specifically tailred t the beneficiary s needs; and identificatin f gals met/nt met
ELEMENT 3 SNP PROVIDER NETWORK Specialized Expertise Use f clinical practice guidelines and transitin prtcls MOC training fr the prvider netwrk
ELEMENT 3 SPECIALIZED EXPERTISE Demnstrate the specialized expertise in the SNP s prvider netwrk Shw hw the SNP determined that its netwrk facilities and prviders were actively licensed and cmpetent Specify wh determines which services beneficiaries will receive Shw hw the prvider netwrk crdinates with the ICT and the beneficiary Demnstrate hw the SNP assures that prviders use evidence-based clinical practice guidelines and prtcls
ELEMENT 3 USE OF CLINICAL PRACTICE GUIDELINES AND TRANSITION PROTOCOLS Prviders are able t review and utilize all Emblem Health Medical Plicies n the plan s website The EmblemHealth Medical Plicies are available in the Clinical Crner Sectin f the EmblemHealth website under the Prvider tab Clinical Crner is a resurce fr practice guidance related t the treatment f acute, chrnic and behaviral health issues, as well, as the medical apprpriateness f specific interventins In additin, EmblemHealth utilizes the McKessn CERME criteria fr Inpatient admissins t Acute Hspitals, Acute Rehab, Skilled Nursing Facilities, review f Prcedures, Durable Medical Equipment (DME) and Hme Care services
ELEMENT 3 USE OF CLINICAL PRACTICE GUIDELINES AND TRANSITION PROTOCOLS SNP Case Management is a vluntary and free value-added prgram fr the majrity f ur members based n benefit package Natinal evidence-based criteria, natinal evidence-based clinical practice guidelines, and Milliman Chrnic Care guidelines are utilized in the develpment f the prgram They are utilized t assist in decisin-making regarding apprpriate health care fr specific clinical circumstances and t imprve health utcmes. EmblemHealth bases its transitin prtcls n the Cleman Mdel f Care Transitins. The term "care transitins" refers t the mvement patients make between health care practitiners and settings as their cnditin and care needs change during the curse f a chrnic r acute illness
ELEMENT 3 USE OF CLINICAL PRACTICE GUIDELINES AND TRANSITION PROTOCOLS The Cleman Mdel f the SNP Care Transitins Prgram aims t: Supprt patients and families Increase skills amng healthcare prviders Enhance the ability f health infrmatin technlgy t prmte health infrmatin exchange acrss care settings Implement system level interventins t imprve quality and safety Develp perfrmance measures and public reprting mechanisms Influence health plicy at the natinal level
ELEMENT 3 USE OF CLINICAL PRACTICE GUIDELINES AND TRANSITION PROTOCOLS EmblemHealth encurages the use f Clinical Practice Guidelines (CPG) by adpting and disseminating practice guidelines fr the prvisin f acute, chrnic and behaviral health services that are relevant t the enrlled membership The Plan uses preventive and cnditin specific clinical practice guidelines t help practitiners and members make decisins abut apprpriate health care fr specific clinical circumstances EmblemHealth established a clinical basis fr its guidelines by identifying and adpting evidence-based clinical practice guidelines that emply natinally recgnized prtcls fr assessment, care and maintenance f health The guidelines are reviewed by clinicians and apprved fr use by the Plan s Health Status Imprvement Cmmittee (HSIC) and all Clinical Practice Guidelines are reviewed at least every tw years and updated as needed, with the exceptin f the HIV/AIDS Clinical Practice Guidelines, which are reviewed and updated annually Clinical Practice Guidelines are available n the plan s Prvider Prtal, in the Prvider Manual and paper cpies are made available upn request frm the prvider Updates are psted t the Prvider Prtal as needed and made available in the Prvider Newsletter
ELEMENT 3 MODEL OF CARE TRAINING FOR PERSONNEL AND PROVIDER NETWORK The SNP Must: Describe hw the SNP cnducted initial and annual mdel f care training Demnstrate hw the SNP assures and dcuments cmpletin f training Specify wh the SNP identified as respnsible fr versight f the mdel f care training Shw what actins the SNP will take when the required mdel f care training has nt been cmpleted
ELEMENT 4 SNP MODEL OF CARE MOC Quality Perfrmance Imprvement Plan Measurable Gals and Health Outcmes Measuring Patient Experience f Care (SNP measurement f satisfactin) Onging Perfrmance Imprvement Evaluatin Disseminatin f SNP Quality Perfrmance
ELEMENT 4 SNP MODEL OF CARE QUALITY PERFORMANCE IMPROVEMENT PLAN The Quality Perfrmance Imprvement Plan is designed t mnitr and evaluate the MOC s structure t ensure that it effectively accmmdates members unique healthcare needs. The MOC structure prvides crdinated and apprpriate care fr ur special needs members Key Objectives Of the Quality Imprvement Plan Are T: Evaluate and imprve members access t clinical and administrative services. Mnitr cntinuity and crdinatin f health care Mnitr and evaluate the current status f the Plan s care and service against reginal and natinal requirements and benchmarks Ensure members access t safe medical and behaviral health care
ELEMENT 4 SNP MODEL OF CARE QUALITY PERFORMANCE IMPROVEMENT PLAN The Individualized Care Plan (ICP) is the initial and nging mechanism used fr frmulating an actin plan based n the member's current health cnditin and medical histry The Plan regularly cllects data frm internal and external surces t evaluate MOC quality perfrmance against measurable gals Stakehlders invlved in the Quality Perfrmance Imprvement Prcess include: A multi-disciplinary team frm Care and Case Management including nurses, physicians, scial wrkers, dieticians, rehabilitatin specialists, pharmacists and behaviral health clinicians A multi-disciplinary team frm Quality Management including nurses, pharmacists, scial wrkers, health educatrs and healthcare analysts
ELEMENT 4 SNP MODEL OF CARE QUALITY PERFORMANCE IMPROVEMENT PLAN All Quality Imprvement activities that impact the SNP ppulatin are mnitred thrugh the Quality Imprvement Prgram Wrk Plan. Quarterly updates are presented t and apprved by the Health Status Imprvement Cmmittee (HSIC) Executive versight is prvided by the Quality Imprvement Cmmittee (QIC) and the Quality Cmmittee f the Bard The Plan integrates SNP-specific measureable gals and health utcmes bjectives int the verall perfrmance imprvement plan. The Plan systematically selects and priritizes SNP quality imprvement prjects in an effrt t achieve the greatest benefit t members Tpics are relevant t and affect a significant prtin f SNP members, and have a ptentially significant impact n member health status and/r satisfactin
ELEMENT 4 SNP MODEL OF CARE MEASURABLE GOALS AND HEALTH OUTCOMES Measurable Gals T imprve access t essential services such as medical, mental health and scial services T imprve access t affrdable care and preventive health services T imprve crdinated care thrugh an identified pint f cntact (e.g., gatekeeper) T imprve seamless transitin f care acrss health care settings, practitiners and health services T assure apprpriate utilizatin f services and cst-effective service and t imprve beneficiary health utcmes The individualized care plan is the initial and nging mechanism used fr frmulating an actin plan t address areas f cncern by evaluating the member s current health cnditin and medical histry Since members can have varying levels f health needs, the individualized care plan prvides a structure t rganize utreaches fr the interdisciplinary care team and t dcument results The individualized care plan is re-evaluated n a regular basis r if the member s health status underges a substantial change
ELEMENT 4 SNP MODEL OF CARE MEASURABLE GOALS AND HEALTH OUTCOMES The Plan s methd fr cnducting and evaluating quality imprvement includes the gathering f claims / encunter data, pharmacy data, lab, vendr, supplemental data surces, medical recrds, survey data, and/r utilizatin management data fr baseline measurement, rt cause analysis and re-measurement including statistical analysis This infrmatin is used t develp and implement apprpriate quality imprvement initiatives and determine the impact f prir quality imprvement initiatives Quarterly the Plan reviews statistical trends f Plan perfrmance in HEDIS/QARR and Star measures t determine the impact f prir quality imprvement initiatives and/r the need fr future quality imprvement initiatives Plan perfrmance is als cmpared t benchmarks that include the NCQA 90th percentile fr Medicare plans and CMS 5 Star Ratings. CAHPS and HOS results are measured and trended annually
ELEMENT 4 MEASURING PATIENT EXPERIENCE OF CARE (SNP MEASUREMENT OF SATISFACTION) Thrugh the Plan s Quality Cmmittee Custmer Experience Service Imprvement Cmmittee (CESIC) Members satisfactin with care and services, as evidenced by the CAHPS results, are cmpared t the Plan and CMS natinal benchmarks Measures that fall belw the gals are analyzed fr rt causes. Opprtunities are ranked, quality imprvement initiatives are recmmended, develped, and implemented t address measures that fall belw gals CESIC includes Plan leaders and clinical staff wh wrk with the SNP ppulatin
ELEMENT 4 DISSEMINATION OF SNP QUALITY PERFORMANCE Imprving Beneficiary Health Outcmes This measurement will capture the results f the SF12 vertime fr SNP members receiving case management services The SF12 (the shrt frm twelve) assesses hw members feel abut their quality f life in relatin t their health This assessment is based upn self-reprted data prvided by the member The SF12 will be administered at the time the member is enrlled int the case management prgram, every six mnths after initial enrllment int the case
ELEMENT 4 ONGOING PERFORMANCE IMPROVEMENT EVALUATION The Plan s Quality Management Department (QM) cnducts an annual review f HEDIS and New Yrk State (NYS) Quality Assurance Reprting Requirements (QARR) measures frm the NCQA measurement dmains and NYS specific measures listed belw t determine which measures will be available fr reprting fr the next calendar year: Effectiveness f Care Measures Cllected Thrugh Medicare Health Outcmes (HOS) Survey Measures Cllected Thrugh CAHPS Health Plan Survey Access/Availability f Care Use f Services NYS Specific Measures
ELEMENT 4 ONGOING PERFORMANCE IMPROVEMENT EVALUATION The list is generated accrding t NCQA, HEDIS and NYS QARR Technical Specificatins and their prgram updates thrughut a calendar year. Using prprietary infrmatin and methdlgy, the Plan reviews categries f infrmatin and ranks prjects accrdingly t determine prject selectin and priritizatin fr assignment f resurces and fcus Criteria include, but are nt limited t, the fllwing: Benchmark indicatrs Regulatry and accreditatin requirements Cntrl f variables and resurces Prject duratin and ppulatin effected
ELEMENT 4 ONGOING PERFORMANCE IMPROVEMENT EVALUATION The Plan s methd fr cnducting and evaluating quality imprvement includes the gathering f claims / encunter data, pharmacy data, lab, vendr, supplemental data surces, medical recrds, survey data, and/r utilizatin management data fr baseline measurement, rt cause analysis and remeasurement including statistical analysis This infrmatin is used t develp and implement apprpriate quality imprvement initiatives and determine the impact f prir quality imprvement initiatives Quarterly the Plan reviews statistical trends f Plan perfrmance in HEDIS/QARR and Star measures t determine the impact f prir quality imprvement initiatives and/r the need fr future quality imprvement initiatives Plan perfrmance is als cmpared t benchmarks that include the NCQA 90th percentile fr Medicare plans and CMS 5 Star Ratings. CAHPS and HOS results are measured and trended annually
ELEMENT 4 DISSEMINATION OF SNP QUALITY PERFORMANCE The Plan will cmmunicate its imprvements made thrugh the Quality Imprvement Prgram via multiple cmmunicatin medias in rder t reach the greatest number f stakehlders Netwrk prviders servicing beneficiaries are kept infrmed f the Plan s prgress thrugh newsletters and Web site pstings Members are sent quarterly newsletters cntaining infrmatin n the Plan s Quality Prgram and initiatives that are targeted twards the Medicare/SNP ppulatin The newsletters als infrm member s that mre infrmatin is available n the Plan s Web site The Plan will peridically evaluate its methd f cmmunicatin fr its prgram and make adjustments as necessary. In additin t the Plan s frmal Quality Imprvement Cmmittee structure that supprts primary cmmunicatin f SNP perfrmance within EmblemHealth, results are shared with all emplyees via the EmblemHealth enet, the Plan s mechanism t cmmunicate imprtant infrmatin t Plan emplyees
ELEMENT 4 DISSEMINATION OF SNP QUALITY PERFORMANCE Adhc cmmunicatins are develped n an as needed basis We cmmunicate HEDIS/QARR measure perfrmance n a quarterly and annual basis t ur large prvider grups and are available fr discussin thrugh established mnthly/quarterly meetings Specific t CAHPS and HOS, the Plan prvides infrmatin n an annual basis using the Member and Prvider Newsletters and website as its primary cmmunicatins channels Infrmatin is shared internally thrugh ur cmprehensive Quality Cmmittee structure and with Plan clleagues via the enet
SPECIAL NEEDS PLAN MODEL OF CARE TRAINING