SNP MODEL OF CARE ANNUAL EVALUATIONS FOR 2013 INSTITUTIONAL/INSTITUTIONAL EQUIVALENT (I/IESNP) DUAL SPECIAL NEEDS PLAN (DSNP) CHRONIC SPECIAL NEEDS PLAN (LSNP) 1 7 0 1 P O N C E D E L E O N B L V D, S U I T E 3 0 0 C O R A L G A B L E S, F L. 3 3 134 1
O V E R V I E W & E X E C U T I V E S U M M A R Y 2013 SNP M ODEL OF CARE ANNUAL EVALUATION Under the Medicare Modernization Act of 2003 (MMA), Congress created a new type of Medicare Advantage coordinated care plan focused on individuals with special needs. Special Needs Plans (SNPs) were allowed to target enrollment to one or more types of special needs individuals identified by Congress as: 1) institutionalized; 2) dually eligible; and/or 3) individuals with severe or disabling chronic conditions. In 2013, Simply Healthcare Plans (SHP) provided care under three SNPs: Institutional/Institutional Equivalent (I/IESNP; Simply Care and Simply Comfort respectively), Dually Eligible (DSNP; Simply Complete), and Chronic Diabetes (LSNP; Simply Level) plans through its contract with the Center for Medicare and Medicaid Services (CMS). As such, SHP is responsible for providing benefits, or arranging for benefits to be provided, for individuals entitled to receive medical assistance under title XIX. Summary of Institutional (I) Special Needs Plan (SNP) and Institutional Equivalent (IE) Special Needs Plan (SNP): The target population consists of Medicare beneficiaries who are residing in a long term care facility (institutional), and also those residing in the community but have met institutional level of care (institutional equivalent). The institutional equivalent members may reside at home or in a community-based setting such as an assisted living facility and must reside in the SHP service area. They are individuals entitled to Medicare Part A and enrolled in Part B and Part D. The Institutional SNP targets those individuals who reside or are expected to reside for 90 days or longer in a long term care facility (defined as either: skilled nursing facility or inpatient psychiatric facility). The Institutional Equivalent SNP targets those living in the community (home or assistive living facility) but requiring an equivalent level of care to those residing in a long term care facility. Summary of Dual (D) Special Needs Plan (SNP): The target population consists of dual Medicare and Medicaid beneficiaries. Simply Healthcare Plans (SHP) received CMS approval to offer a dual eligible SNP beginning in January 1 st, 2012. Since SHP contracts with the state of Florida to cover Medicaid services, SHP is managing dual eligible beneficiaries Medicare and Medicaid coverage and coordinates with other plans for the Medicaid long-term care benefit. Summary of Chronic (L) Special Needs Plan (SNP): 2
The target population consists of persons eligible for Medicare benefits and services and living with diabetes mellitus, type 1 or type 2; around 20% are Hispanic and many are not fluent in English. They must reside in the SHP service area and have Medicare Part A, Part B, and Part D and must not be under treatment for ESRD (end-stage renal disease). Many may also have Medicaid benefits. For all SNP plans, SHP believes that providing the specialized care delivery systems across all domains may result in improved outcomes, lower costs and have a positive impact on the members overall health and quality of life. Annual Evaluation Process: SNP programs each follow an approved Model of Care (MOC) which describes the care and resources to be provided to members from the health plan. As a SNP, SHP is responsible to conduct an annual evaluation of programs. The M O C Taskforce, c o m p r i sed o f r e p r e senta t i v e m e m b e r s f r o m k e y S H P d e p a r t m e n t s ( i. e., Quality Management, Health Services, Member Services, Medical Economics, Compliance, and Provider Relations, etc.), collects, analyzes, and reports on data that is used to evaluate the effectiveness of each SNP MOC towards goals. In this process, the MOC Taskforce develops key findings and identifies any follow-up actions needed. SHP utilizes various tools to measure and track the progression of the goals and timely identification of barriers. These include reports, aggregate and detail level run at various time frames (monthly, quarterly, bi-annually and annually). The outcomes of the goals a r e measured utilizing a variety of tools including, but not limited to: the Health Risk Assessment (HRA); chart audits; ER, SNF, and hospitalization utilization; satisfaction surveys; health outcomes survey questions; call center statistics; pharmacy benefit review; and interim HEDIS measures. The results are summarized at an organizational level to identify areas of strength and opportunities to improve the MOCs for each of the individual goals measured. Key Findings & Recommendations Goal 1: Improve Access to Affordable Medical, Mental Health, and Social Services SHP strives to facilitate provision of, and access to appropriate, timely and cost-effective health care services and treatment in the least restrictive setting and manner. When the health care needs can be anticipated and identified early in the continuum of care, members can often be assisted with less intense and intrusive services. By working closely with the member/caregiver, primary care physician, and ancillary providers, the care manager can anticipate required services and arrange these to be provided in the most cost-effective setting and provide quality care to meet the member s health care needs. SHP s MOC Taskforce has determined that this overall goal has been met for each of the SNPs. Based on the results achieved, SHP will continue to assess the adequacy of performance indicators towards demonstrating that the continuum of comprehensive health care needs are met. Interdisciplinary Care Team (ICT) initiatives implemented in the latter part of 2013 to ensure increased and improved collaboration and participation of providers 3
and members in ICT meetings will remain in effect for 2014. Improvements were noted in the fourth quarter within the I/IESNP plans where implementation occurred earlier. Monitoring of gap analysis and benefit design will continue as there were no adverse trends identified within the network and benefit designs were found to favorably meet the target population needs in each SNP. Interim HEDIS results revealed the following by Plan: I/IESNP demonstrated a 12.2% improvement in Adult's access to Preventive / Ambulatory Health Services (AAP) for members 65 years and older. Initiatives implemented in 2013 are demonstrating effectiveness and should continue in order to close the gap between SHP performance in this area and the national mean. DSNP and LSNP demonstrated National Mean benchmarks for Adult's access to Preventive / Ambulatory Health Services (AAP) for members 65 years and older were met or exceeded. DSNP also had sufficient data to demonstrate that benchmarks for mental health measures regarding Antidepressant Medication Management and Initiation and Engagement of Alcohol and Other Drug Dependence Treatment were exceeded. Chart audit initiatives implemented in 2013 to increase completion rates for all plans have been very successful. Although most chart audit indicators related to this goal were met, stricter interpretation and application of standards have revealed opportunities for improvement. Follow-up recommendations are: All SNPs: To revise case manager standard operating procedures to include mental health and community/social service coordination expectations and documentation standards. Provide staff training on these indicators and continue to monitor chart audit results monthly to provide necessary feedback to case managers. Medicare behavioral health performance indicators for outpatient visits, expedited service requests, and percentage of outpatient denials were met. Based on the results achieved, SHP will continue to assess performance indicators to assess that access to affordable medical, mental health and social services is provided. Goal 2: Improved coordination of care through an identified point of contact or gatekeeper SHP s MOC Taskforce has determined that this overall goal has been met for all SNPs. In 2013, case management participation rates were within targeted or anticipated range. Health risk assessment (HRA) completion rates improved significantly in 2013 across programs. The I/IESNP and LSNP programs well-exceeded the new 80% goal; however, the DSNP fell shortly below the goal at 75% overall. Current HRA action plans will remain in place as they are proving effective. Chart audits results over 11 indicators were met across the board for the DSNP. The I/IESNP and LSNP did reveal some areas for improvement as follows: Documentation of initial Care Plan provision to the PCP and member. Documentation that updates to the Care Plan were provided to the PCP and Member (I/IESNP only). 4
Provider Medical Record Reviews were used for the first time in the MOC Annual Evaluation and yielded impressive results. Many providers were sampled and each found to be above the goal of the 85 th percentile, average ranking 90%, in meeting the General Medical Component requirement. Member ratings of overall Case Management Program effectiveness were high and satisfaction survey results were very positive overall. Certain opportunities for improvement were noted and both overlapping and distinct between plans. A lower than 80% agreement rate was found for the following survey statements: The case manager mailed me a copy of my initial care plan and updated me when there were changes. (All Plans) Educational materials were easy to read and understand. (I/IESNP and DSNP) Educational materials were provided in the language that I speak. (IESNP) The case manager encouraged me to be an active participant in setting goals and in the development of my Care Plan. (DSNP and LSNP) The case manager mailed me a copy of my initial Care Plan and always updated me when there were changes. (DSNP and LSNP) The case manager notified me timely to invite me to participate in my ICT conferences. (DSNP and LSNP) Survey areas of greatest agreement and strength in all SNPs were: The CM introduced themselves and why they were calling. Each time the case manager contacted me he/she spoke a language I could fully understand. I was always encouraged to ask questions. I was always treated respectfully. The MOC taskforce determined that education related results for the I/IESNP population are skewed as this is a home visiting program and education is usually provided verbally between the CM and the member/caregiver. Consequently, the Taskforce recommended re-wording future education survey questions for this population to focus on verbal education. Follow-up recommendations are: continue ICT meeting member and provider engagement efforts, provide documented training to both I/IESNP and LSNP case managers on care plan collaboration and documentation requirements/standards; revise satisfaction survey questions (I/IESNP) to elicit needed feedback regarding effectiveness and relevance of education provided by case management; and review and revise ICT invitation process and materials (DSNP and LSNP). No changes were made regarding education materials for the DSNP program as improvements implemented in the last half of 2013 resulted in progress from 2012 and should continue. Based on the results achieved, SHP will continue to assess performance indicators to ensure improved coordination of care through a single point of care management. Goal 3: Improve Transitions of Care Across Settings and Providers 5
SHP s MOC Taskforce has determined that this overall goal has been met. There were four (4) chart audit indicators reviewed with positive results. All transition of care indicators were met for the I/IESNP programs and the DSNP program (one of the indicators was not applicable in the DSNP). File selection for the LSNP program did not produce applicable results as transition of care needs were not identified in any of the charts reviewed. Selection of charts is random based on active case management members during the month reviewed. Member Services readiness and accessibility indicators (abandonment rate and speed of answer) were positive, were within standards and reflect continuous availability of assistance that is integral to resolving any transition issues. In addition, the new After-Hours Nurse Triage Line is an enhancement that can reduce unnecessary utilization in the future although low utilization rates were found for this service in the SNPs. Transition of Care (TOC) process improvements were made in 2013 that both enhance the Plan s Quality Improvement Program (QIP) and ability to meet SNP Structure and Process requirements. Key changes in this area are expected to result in further improvements in 2014 as they will be in effect for a full year. Readmission rates have improved for I/IESNP members significantly, 550% improvement for the ISNP and 18% improvement for the IESNP. This is determined to be a result of the process improvements made and collaboration between Case Management, Quality Management, and the new Transition of Care Team. DSNP and LSNP results were also for readmission rates also met the goal. Emergency Room (ER) visit rates were reduced in 2013 for the I/IESNP programs but increased in the DSNP and LSNP programs where additional counties and population were being newly served in 2013. The MOC Taskforce concluded that based on an overall downward trend for ER utilization rates, the measures currently in place and added in 2013 should show an impact with time; however, some of the lack of stabilization in these programs are attributed to the addition of counties that have higher ER utilization rates overall. The benchmarks and goals set were based on 2012 trends in the DSNP program. These goals have been revised for 2014 based on the new 2013 benchmarks. Based on the results achieved, SHP will continue planned efforts to improve transitions of care across settings and providers with no corrective actions needed. Goal 4: Improve Access to Preventative Health Services SHP s MOC Taskforce has determined that this overall goal has been met. Interim HEDIS results show multiple improvements over the National Mean and over 2012 results where comparative data was available. The plan provides abundant access to preventive health services through its network and benefits. Members are encouraged to avail themselves of these services by providers, case managers, and through additional special initiatives under the QIP and CCIP. Interim HEDIS results for seven (7) indicators demonstrated the success of collective efforts within the Plan and its network to assist members in accessing preventive 6
health services. The main opportunities for improvement identified within the HEDIS indicators were as follows by plan (plans not mentioned met or exceeded goals): Increase the number of eye exams completed for diabetics and continue to monitor progress through the STARS workgroups. Case Management should review employee level efforts monthly and address as needed. (I/IESNP and DSNP) Preventative care results show this is a significant areas of strength across SNPs. All Care for Older Adults measures exceeded national benchmarks by a wide margin. Diabetic testing, nephropathy care, and LDL screenings were also above the goal. Based on the results achieved, SHP will continue planned efforts to improve access to preventative health services. Goal 5: Assure Appropriate Utilization of Services SHP s MOC Taskforce has determined that this overall goal has been met with significant improvement over 2012 results in certain indicators. Chart audit findings demonstrate that member utilization is being monitored, members are assisted in obtaining needed services, case managers are properly facilitating needed care, and the most cost-effective settings for care are being used rather than a hospital when appropriate. Provider medical record reviews conducted by the Quality Management Department demonstrated no adverse trends in the network for all SNP populations served. In the I/IESNP programs, significant improvement variances between 57% and 123% were realized in 2013 admission and ER rates in comparison to the prior year. Admission an ER visit rates for the DSNP and LSNP programs did not meet the goal set based on the 2012 benchmarks but measures already in place have been approved to continue. The goals for these programs have been adjusted for 2014 to accurately benchmark for the additional counties and networks served as well as the new LSNP (diabetic population) based on results achieved. Transition of Care (TOC) team and post-discharge initiatives implemented during 2013 are expected to demonstrate full impact in 2014. Based on the results achieved, SHP will continue planned efforts to assure appropriate utilization of services. Goal 6: Improve Member Health Outcomes SHP s MOC Taskforce has determined that this overall goal has been met. Member health outcomes are evident through a variety of measurement sources. Utilization measures discussed in other areas for admission and ER rates were also applicable towards this goal with ongoing monitoring and application of the QIP recommended. Skilled Nursing Facility (SNF) admission rate goals were met for the I/IESNP and DSNP populations with a significant reduction in SNF admissions achieved within the ISNP 7
program. The LSNP program was over the goal of 10% by 3% and, while within a 5% range, will continue to be monitored closely. Health outcomes are often influenced by member self-perception of health and support. For all SNPs, Health Outcome Survey (HOS) survey results show that while services and assistance received has been perceived favorable to meeting member needs and maintaining/improving health, a much lower percentage of members report that health has actually improved or remained stable. The proportion of those replying somewhat agree was greater than anticipated given the contradicting evidence (e.g., perception of needs met, improved risk scores, decreased utilization). One explanation can be found in the Annual HRA comparisons in which a decreased ability to complete activities of daily living has been reported. After a review of literature on self-perception of health, the MOC Taskforce recommended to change the second question response options to very good, good, fair, and poor to allow for a more nuanced response. This will be implemented in the next survey and current results will be used as a benchmark. New indicators were added for the I/IESNP and DSNP programs related to annual Health Risk Assessment (HRA) comparisons (LSNP only active one year). These yielded interesting findings and provided insight into our member population when comparing responses from HRAs conducted in 2012 to those conducted for the same members in 2013. A significant percentage of members maintained or improved risk levels. Prevalence rates reviewed indicate that disease management paths and existing clinical guidelines are focused appropriately to the significant health concerns of members. An increase was found in member self-reporting of Congestive Heart Failure (CHF) as a health condition. This is thought to be a result of increased awareness through the CHF program. Another significant change is that significantly fewer members reported depressive symptoms and falls after one year in the programs but an increased number of members reported decline in ability to complete activities of daily living. Lastly, seven (7) interim HEDIS measures for diabetic HbA1c control, diabetic LDL-C control, High-Risk Medication usage, and monitoring for patients on ACE inhibitors and/or diuretics were analyzed. All measures were met or exceeded with exception to the following by program: HbA1c Control <8% (I/IESNP and LSNP) HbA1c Poor Control >8% (I/IESNP) LDL-C Level <100mg/dl (I/IESNP and DSNP) For the above measures, an improvement from current rates is expected as records continue to be received. These improvements are not expected to significantly improve the measure for HbA1c Poor Control in the I/IESNP program which fell significantly short of the goal. Recommendations were for the STARS Taskforce to continue to closely monitor Diabetic HEDIS measures for improvement with special attention to the aforementioned. Case management is also advised to ensure members with poor HbA1c control are brought before an IC meeting to discuss means to improve member outcomes in this area. 8
Based on all results achieved, SHP will continue planned efforts to improve member health outcomes. Conclusion for MOC Annual Evaluations: The Simply Healthcare Plans MOC Annual Evaluation Taskforce has concluded that overall goals for each Special Needs Plans have been met; however, several opportunities for improvement are noted within specific supporting measures. In these areas, on-going close monitoring or new follow-up actions are needed in response to key recommendations. New follow-up actions to be taken and any improvements made are to be reported in subsequent Quality Improvement Committee Meetings. 9