MCS Model of Care For Special Needs Plans (SNP) Annual training for delegated entities and facilities

2018 MCS Model of Care For Special Needs Plans (SNP) Annual training for delegated entities and facilities Quality Department CAN_2790318S

CMS Requirements The Centers of Medicare & Medicaid Services (CMS) requires that all MCS employees, Delegated Entities and its providers receive the Model of Care of Special Needs Plan training upon hire and annually thereafter. CMS requires that MCS ensures a 100% compliance with initial and annually trainings for all employees and providers. 2

Training Objectives Name the four (4) Model of Care elements, aimed at improving healthcare for D-SNP (Special Needs Plan) members. Describe the Model of Care that MCS offers to its dual eligible members (D-SNP). Describe the Interdisciplinary Care Team (ICT) interventions and the development of the Care Plan (ICP) as part of the Care Coordination. Explain the integrating role of employees and providers in the Model of Care of MCS. 3

Definitions 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. CHRA (Comprehensive Health Risk Assessment) Assessment performed by clinician personnel to identify needs and member risk factors. CM (Care Management): Care Management Program/Care Manager 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. HOS (Health Outcomes Survey): Surveys that gather valid and clinically significant data on patients mental and physical wellness. ICP (Individualized Care Plan): Individualized Care Plan created for the member. ICT (Interdisciplinary Care Team): Interdisciplinary Care Team responsible for the care plan development, care coordination, among others. MOC (Model of Care): Model of Care. PCP (Primary Care Physician): Primary Care Physician responsible of the member principal care plan under the Coordination Model of Care. 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. 4

Special Needs Plans Background 2003 Under the Medicare Modernization Act, the U.S. Congress developed the Special Needs Plan (SNP),as part of the requirements for the Medicare Advantage plans (MA). SNP s are classified in three categories: Dual Eligibles (D-SNP) Chronic Diseases (C-SNP) Institutionalized Individuals (I-SNP) 2012 Affordable Care Act amended Section 1859(f)(7) of the Social Security Act: Requires that all MA plans offering SNPs plans submit a Model of Care (MOC) to CMS for the evaluation and approval of NCQA (National Committee for Quality Assurance) that ensure compliance with the CMS guidelines. CMS regulation 42 CFR 422.101(f) requires that all MA insurance must implement a Model of Care for its members with Special Needs to satisfy their health needs and improve their quality of life. 5

Definition: MCS Classicare Platino Special Needs Plans Background Health plan for people who are eligible to receive benefits from Medicare Parts A and B, and Medicaid. Medicare A+B Medicaid D-SNP MCS has a contract with Medicare and can offer Platino products to their dual elegible beneficiaries. 6

Model of Care (MOC) CMS describes the Model Of Care as a vital quality improvement tool that integrates components 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. MCS Quality Department is responsible for overseeing, monitoring, and evaluating actions related to MOC. D-SNP Access to services Care management Coordination of care Improve health results Guarantee quality services 7

Support Components for MOC Member MCS s MOC has the necessary structure to communicate and satisfy the needs of our SNPs members. Performance Evaluation MOC Taskforce Clinical Guidelines MOC CHRA ICT Communicates on a regular basis the medical management, cognitive, psychosocial and functional status to the member and his or her PCP and includes the caregiver as necessary. The initiatives facilitate the preauthorization processes, care transition, chronic condition follow-ups, and communication between providers. Providers Network ICP The MOC performance and its components are evaluated regularly to guarantee compliance with the CMS guidelines. 8

Model of Care (MOC) MOC is composed of four (4) elements: MOC 1 MOC 2 MOC 3 MOC 4 Description of SNP Population Care Coordination Care Transition Protocol Providers Network Measures and Evaluation of Quality Improvement 9

MCS Classicare Platino 2018 Products In 2018, MCS has (6) Platino products for SNP population. Product Name MCS Contract Number MCS Group Number MCS Classicare Platino Ideal HMO SNP H5577-002 (Renewal) 850614 Platino Progreso HMO SNP H5577-017 (Renewal) 850717 Platino Original HMO SNP H5577-026 (New) 850720 Platino Cómodo HMO SNP H5577-027 (New) 850721 Platino Clásico HMO SNP H5577-028 (New) 850722 Platino Más Ca$h HMO SNP H5577-029 (New) 850723 On December 2017, the total MCS D-SNP population was 94,492 members. 10

MOC 1 MOC 2 MOC 3 MOC 4 Description of SNP Population Care Coordination Care Transition Protocol Providers Network Measures and Evaluation of Quality Improvement 11

MOC 1: Description of SNP Population MCS Classicare Platino Total population SNP General Population 94,492 members SNP Most vulnerable population 15,116 members The most vulnerable population of the MCS Classicare Platino total population in which complex health risks were identified that require intervention of a Care Manager to assist their needs. 2016 Data 12

MOC 1: Description of SNP Population Important data to describe the population: Eligibility Social factors, cognitive and environmental Life conditions Comorbidities Physical and mental health conditions Specified characteristics identified in the population 62.7% have 65 years or more. 56% of the population are female. 46% live in rural zone. 53% report requires a caregiver. Three principal diagnoses identified in SNP population are: 1. Diabetes Mellitus 2. Hypertension and 3. Ocular Refraction Disorder 7% of members didn t visit their PCP during 2016. According to the Health Outcome Survey (HOS), 84% of the participants stated their mental health status improved compared to previous year. 47% didn t complete high school. 99% identify as Hispanic. 99.75% prefer Spanish as their principal language. 2016 Data 13

MOC 1 MOC 2 MOC 3 MOC 4 Description of SNP Population Care Coordination Care Transition Protocol Providers Network Measures and Evaluation of Quality Improvement 14

MOC 2: Care Coordination Regulations 42 CFR 422.101(f)(ii)-(v) and 42 CFR 422.152(g)(2)(vii)-(x) require that all SNPs coordinate and evaluate the effectiveness of the services provided as required by the MOC. Care Coordination ensures coverage of all SNP member health needs and service preferences. Also ensures that medical information between health professionals is shared, maximizing effectiveness, efficiency, high quality of services and improvement of member health. MOC also describes the roles, responsibilities and vigilance of clinical and nonclinical personnel. MOC establishes a contingency plan that ensures the continuity of critical functions inside of MCS operation during an emergency. Also requires all personnel must complete MOC training upon hire and annually. 15

MOC 2: Care Coordination Integral Role of the Employees Ensure compliance with CMS requirements for the MOC. Participate in the initial and annual MOC training. Assist members and providers satisfying their service needs. Support initiatives to comply with MOC goals. 16

MOC 2: Care Coordination Personal Structure Health Risk Evaluation Care Plan Interdisciplinary Team (ICT) Care Transition Clinical Personnel Requires credentials Non - Clinical Personnel Support personnel MCS provides initial MOC training and annually to all its employees and contractors. CHRA Initial conducted within the first 90 days of enrollment. Annually conducted within 12 months from the last CHRA evaluation. Care Plan Conducted based on identified needs in HRA (CHRA). MCS Interdisciplinary Care Team Standard Complex Transition Types Planned Non-planned 17

MOC 2: Care Coordination CHRA Health Risk Evaluation Comprehensive Health Risk Assessment (CHRA) is a tool designed to gather all the elements that help to identify our members needs. Consists in a risk evaluation realized by a clinical personnel during the first 90 days of affiliation and annually before the12 months of the last CHRA. The CHRA sections are carefully selected by the Interdisciplinary Care Team (ICT) to evaluate possible risks and needs of members both clinical and non-clinical. In case of any change in the member health status, the CHRA or General Assessment (GA) should be updated. 18

MOC 2: Care Coordination Health Risk Evaluation identified in the CHRA Medical Psychosocial Functional Mental Health Cognitive 19

MOC 2: Care Coordination Health Risk Evaluation CHRA 2018 Clinical Information Section Non-Clinical Information Section The identified needs in the CHRA determine the health risk level of each SNP member are between: low-moderate-severe 20

MOC 2: Care Coordination CHRA Health Risk Evaluation Health Levels Logistics based on the obtained score in CHRA Standard Individualized Care Plan is required annually. Low > 65 points Standard Individualized Care Plan is required annually. Moderate >20-65 points Individualized Care Plan is required annually for Complex and Care Management Intervention. Severe < = 20 points 21

MOC 2: Care Coordination Individualized Care Plans A high qualified Interdisciplinary Care Team (ICT) develops an Individualized Care Plans (ICP) according to the member health risks identified in the CHRA. Member Stratification ICT Standard ICT Complex Care Management Unit Low Moderate Complex (Most Vulnerable Population) 22

MOC 2: Care Coordination Interventions and recommendations established in the Care Plans based on the following criteria: Preventive Care by Age and Gender Women <65 years >65 years Men <65 years >65 years ICT Standard Risk Level: Low or Moderate Current Chronic Diseases Cardiovascular Diabetes Respiratory Diseases Renal Diseases Arthritis Osteoporosis Hepatitis C HIV/AIDS Depression Mood Disorders Alzheimer s Hypothyroidism Assessment of Individual Needs Performed by a Care Manager to establish specific interventions that address the member s health status. ICT Complex Risk Level: Severe 23

MOC 2: Care Coordination Information sources and processes to generate Care Plans Initial Referral Source RAPS CHRA Health risk levels according to reported diagnostics and demographic data Members with risk level: Low to moderate Members with risk level: Severe Preliminary Care Plan based on age, gender and found diagnostics in referral sources. Refer to Care Management HCC Individual risk evaluation completed by a Care Manager Individualized care plan is established taking in consideration the General Assessment responses, age, gender and identified diagnostics by the CM. 24

MOC 2: Care Coordination Individual Care Plan format includes: Header Member Name Contract Number Primary Care Physician Name Situation Age and gender Member s chronic conditions Interventions Preventive self-care recommendations by age, gender and chronic conditions Support interventions MCS interventions to promote member s health care PCP interventions For the evaluation and management of member s health 25

MOC 2: Care Coordination Communication Process and Care Plan Update Low and Moderate Care Plan at least once a year. Care Plan is modified if a new CHRA reported changes in risk levels of diagnoses. A letter is generated with the information of the member s plan and shared with him or her, his or her PCP including the CM electronic system. Severe Care Plan is revised and discussed with the member as needed and is sent at least every 6 months, modified according to the member s health needs while participating in the Care Management Program. A letter is generated with the Plan for the member and his or her PCP and is included in the CM electronic system. The Care Plan is available for the ICT through CM. * Every letter and care plan are sent via postal mail to the member and PCP. 26

MOC 2: Care Coordination Efforts to promote interventions and recommendations of the Care Plan With Members Individual Care Management interventions on members with severe risk 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 With Primary Care Physician Delivery and discussion of quality measure report by PCP Clinical management warning letters Accredited clinical educational interventions with continuing education Educational campaigns Clinical care coordination call on members with severe risk MCS MOC annual training 27

MOC 2: Care Coordination Interdisciplinary Care Team The Interdisciplinary Care Team (ICT) provides the structure and necessary processes to offer and coordinate services for the health care of our MCS Special Needs Plan members, according to the identified health and needs status. Interdisciplinary Care Team Standard Care Management RN Social Worker Interdisciplinary Care Team Complex Care Management RN Care Management Manager RN Member/Caregiver Primary Care Physician Pharmacy Health Educator Member/Caregiver Primary Care Physician Care Management Director RN Social Worker Mental Health Pharmacy Utilization Management Mental Health Information Management Other Members *Ad Hoc 28

MOC 2: Care Coordination Care Transition Transition of Care is.. When a member has a health status change and requires a transition from one health setting to another. Transition of Care to decrease the level: Example: From hospital to a Rehab and then to the patient s home. Transition of Care to increase the level: Example: From patient s home to the hospital. 29

MOC 2: Care Coordination Care Transition Unplanned Transition Emergency visit that involves hospital admission. Planned Transition Elective surgery or planned procedures Skilled Nursing Facility (SNF) Home Health Agency Admission (HHA) MCS accounts for different Transition of Care protocols to facilitate our members when changing from one health care setting to another according to their needs. 30

MOC 2: Care Coordination Care Transition During Care Transition we educate our members through: Care Transition Letter to the member and its PCP Medilínea 24/7 Educational materials on self-care (Cuídate Magazine, preventive reminders for diabetes, cardiovascular conditions, among others) Phone calls from a nursing professional 31

MOC 1 MOC 2 MOC 3 MOC 4 Description of SNP Population Care Coordination Care Transition Protocol Provider Network Measures and Evaluation of Quality Improvement 32

MOC 3: Providers Network Providers Trainings Clinical Guidelines and Care Transition Protocols Primary Care Physicians Specialists: -Internal Medicine -Endocrinology -Cardiology -Among others Experts on Mental Health Services -Among others MCS offers initial and annual MOC training to all its providers -Participants -Non-Participants that assist MCS members routinely Delegated Entities: -FHC -Eye Management -TNPR -Among others MCS adopts, revises and shares clinical guidelines to support the PCP and member in decision making of the appropriate medical care. Care Transition -Continuity of Care Clinical Guidelines Examples: -Diabetes -Asthma -Cancer MCS ensures the care continuity to our members through transition protocols 33

MOC 3: Providers Network Primary Care Physician and Specialists Role Participate in planning patient s care Provide the necessary medical care Provide education about the condition to member and/or caregiver Offer preventive care and direct members to maintain a healthy lifestyle Encourage the patient to participate in their care process (self-care) 34

MOC 3: Providers Network Role of the Primary Care Physician and Specialist Physician Participate in interdisciplinary team meetings Maintain communication with the care manager, the interdisciplinary care team and/or caregiver and work together on the Individual Care Plan Provide access and integrate other physicians or providers into the patient care management, as necessary Use the Clinical Practical Guidelines (CPG) adopted by MCS (available in Provinet). Revise and update the care plan, answer the member preferences and/or concerns. Ensure the continuity of care and/or services to the patient, and provide follow-up treatment. 35

MOC 3: Providers Network Primary Care Physician Role and Specialist Provide necessary medical care Incorporate the Primary Care Physician on member s care Notify the medical plan of any barrier identified that affects service access or the transition care process Encourage patients to participate in their care process Provide services on time, effective and guaranteeing service quality. 36

MOC 3: Providers Network Provinet: Provider s Tool https://provinet.mcs.com.pr/ 37

MOC 3: Providers Network Assistance to the PCP to coordinate the care of the member (Gap in Care) The provider can evaluate the compliance of the patient in measures of preventive care and HEDIS in Provinet. HEDIS Measures 38

MOC 3: Providers Network MCS Advantage Clinical Guidelines accessible for Providers Clinical Guidelines are available in Provinet Some Examples: Asthma Cancer Among others https://www.mcs.com.pr/es/proveedores/paginas/guias_clinicas.aspx 39

MOC 3: Providers Network MOC Training: Accessible for providers through Provinet Our providers can access the MOC Trainings through Provinet. https://provinet.mcs.com.pr/documentcatalog/search 40

MOC 3: Providers Network Referral for Care Management Program Referral for potential members for Care Management Programs Send fax: 787.620.1336 Document available in Provinet 41

MOC 1 MOC 2 MOC 3 MOC 4 Description of SNP Population Care Coordination Care Transition Protocol Providers Network Measures and Evaluation of Quality Improvement 42

MOC 4: Measures and Evaluation of Quality Improvement MOC Taskforce BOD MOC QIC UMC MCS s MOC is currently approved for a cycle of 3 years (2018-2020). Requires annual approval of MCS Board of Directors, Utilization Committee and Quality Committee. The MOC Taskforce composed of the management team of areas impacted by the MOC meet at least six (6) times a year to discuss and monitor the operational compliance with MOC requirements including measures aligned to STARS, HEDIS, CAHPS, HOS and those of its own departments. 43

MOC 4: Measures and Evaluation of Quality Improvement Data Sources: CM CHRA, PMHS applications MCS leaders participate in the internal quality process. A. Quality Performance and Improvement Plan B. Measurable Goals and Health Outcomes Measures & indicators STARS HEDIS Regulatory reports Operational reports Satisfaction Surveys CAHPS HOS Internal surveys of members satisfaction Focus Groups C. Measuring Patient Experience of Care D. Ongoing Performance Improvement and Evaluation of the MOC Monitor and analyze the quality indicators to identify improvement opportunities. MOC Taskforce meetings. The MOC is presented for Program Evaluation in the MCS Quality Committee. MCS communicates the obtained information to: Board of Directors Employees Providers Among others E. Dissemination of SNP Quality Performance Related to the MOC 44

Thank you for your commitment to improve the quality of life of our members! 45

References MCS SNPs (2018) Model of Care Description Medicare Managed Care Manual-Chapter 16-B: Special Needs Plans (Rev.98, Issued: 05-20-11, 05) Medicare Managed Care Manual-Chapter 5 - Quality Assessment (Rev. 117, 08-08-14) MOC Scoring Guidelines CY (2018) 46

We are here to serve you Any further information you can contact: Larry Keeley Sr. VP of Compliance Envolve Vision Benefits, Inc. Direct: 800.334.3937 EXT. 49247 Larry.Keeley@EnvolveHealth.com 47