snp approval model of care requirements surveyor training brett kay, sandra jones, nidhi dalwadi...

SNP APPROVALModel of Care Requirements

Surveyor Training

Brett Kay, Sandra Jones, Nidhi Dalwadi Mehta February 4 & 9, 2015

2SNP Approval MOC Requirements

Surveyor Training for CY 2015

Purpose of Training• SNP Approval MOC reviews

– Provide brief overview of CMS’s 2016 SNP Approval application process

– Project Timeline

• Provide a general understanding of main components of SNP Approval– Model of Care (MOC) Requirements

(Elements 1-4)

– Scoring Guidelines & Methodology

– Surveyor FYI & Reminders

Objectives of Special Needs Plan/Medicare-Medicaid Plan (SNP/MMP)

Model of Care Review

• Comply with statutory requirements of Affordable Care Act

• Ensure SNPs and MMPs have robust Models of Care

• Establish frequency for approval review cycle (1-3 years)

Project Time Line

• February 3 – Technical Assistance call prior to submission

• February 18 – SNP Applications submitted to CMS via HPMS

• April 20 – CMS issues Notice of Intent to Deny

• April 23 – TA call for Plans scoring <70%

• April 30 - SNP Cure Apps due in HPMS

• May 27 – CMS issues SNP Denial Notices

• June 1 - SNP bids due to CMS

SCORING GUIDELINES

• Scoring will be similar to previous years

• Most elements composed of multiple factors • MOC elements worth 0-4 points, based on #

of factors met. • Plans must provide a comprehensive

description that provides “the what” & “the how” in response to each element & factor

• Total of 60 points (15 elements) converted to percentage scores– E.g., 50 points = 83.33% (2-year approval)

• Requires a minimum passing score of 70 percent

How will NCQA Score the MOC?

Crosswalk to New ElementsOld ElementsNew Elements

• MOC 1: SNP Population

• MOC 2: Care CoordinationCare Transitions Protocol

• MOC 3: Provider Network

• MOC 4: Quality Measurement

MOC 1: SNP-specific Population

MOC 10: Vulnerable Populations

MOC 3: Staff Structure/Care Management Roles

MOC 4: Interdisciplinary Care Team

MOC 7: Health Risk Assessment

MOC 8: Individual Care Plan

MOC 9: Communication Network

MOC 5: Provider Network & Use of Clinical Practice Guidelines

MOC 6: MOC Training

MOC 2: Measurable Goals

MOC 11: Outcome Measurement

MOC Scoring Implications

• Multi-year approval based on MOC scores --85 percent or higher = 3 years --75 percent to 84 percent = 2 years --70 percent to 74 percent = 1 year

• SNPs must identify all of the H numbers that fall under the same MOC on the SNP MOC Matrix Upload document– While the MOC is the same – we want to see specificity on the

target population at the local service area (PBP) level, not the national level. Make data and analysis relevant to specific populations in each service area

– Expectation is for SNPs to submit a new MOC each renewal period with process updates and changes (e.g., changes to goals as a result of analysis of outcomes or process improvements), and not the same MOC previously approved

– MOC will receive a new score

Updates for this Review Period

Cure Opportunities

• SNPs that score >70% after initial review will not have an opportunity to cure. Their score will be final after the initial review.

• SNPs that score <70% after the initial review will have one cure opportunity. After that cure, regardless of the score, the plan will receive a one-year MOC approval status.

• Example: SNP A receives a score of 67% after initial review. Then, receives a score of 87% after cure 1. Even though a score of 87% provides a three-year approval, because the plan scored <70% initially, they are only eligible to receive a one-year approval.

Questions & Answers

Sandra Jones

MOC 1: Description of SNP Population

Intent: Identify and describe the target population, including health and social factors, and unique characteristics of each SNP type• Focus is on a description that:

- Provides a foundation upon which the remaining measures build a complete continuum of care (e.g., end-of-life & special considerations) for current and potential members the plan intends to serve.

- Includes specially tailored services for members considered “most vulnerable” (e.g. multiple hospital admissions or excessive spending on medications above set limits)

MOC 1: Description of SNP Population

MOC 1 Element A: Overall SNP Population-Factor 1

Factor 1• MOC Description: Emphasis is on process and relevant

resources used, not care coordination:– Member identification

– Verification of eligibility

– Tracking

• Process includes information on systems or data collection methodology used to identify and track eligible beneficiaries

• Description of the target population—must address specific population of SNP’s service area(s)

Factor 2There are separate requirements for social and medical/health factors; the focus is on social, cognitive and environmental factors:• MOC description must also include

– Social & environmental factors; living conditions– Cultural or linguistic challenges– Barriers to health care delivery– Caregiver concerns

• Potential factors that may interfere with provision of health care or services, caregiver considerations or other concerns.

Factor 3Focus is on medical/health/cognitive factors • MOC description must also include

– Current health status of members– Associated behavioral health issues– Comorbidities

• Disease characteristics that could impact present status

Factor 4• Characteristics of population per SNP type

– Includes limitations & barriers that affect overall health

• C- SNP – chronic conditions, incidence & prevalence

• D-SNP – define subtype (e.g., full, partial) as well as health conditions, including limitations & barriers

• I-SNP –Facility type; specialty providers & services; limitations & barriers

True/False

The organization’s MOC should describe the needs of the target population that is specific to

the locale or geographic area for each plan.

Polling Question

Intent: Describe the most vulnerable beneficiaries and how their medical/social factors affect health outcomes and what services/resources the SNP provides to address these factors• Focus:

- Important to note that the focus is on population-level, not individual members

- Simply put, what makes them “different from the general population”?

MOC 1B: Most Vulnerable Beneficiaries

Factor 1• Plan definition of “most vulnerable” and includes:

– Robust & comprehensive description of members

– Methodology used for identification (e.g., specify data collected from various resources, multiple admits/readmits, high pharmacy utilization, high risk stratification, specific diagnosis & subsequent treatment required)

– Medical, psychosocial, cognitive or functional challenges

– Any specially tailored services geared towards this population

MOC 1 Element B: Most Vulnerable Beneficiaries-Factor 1

MOC includes a description of the most vulnerable members, specifically:Factor 2• Explain how certain characteristics (e.g., average age,

gender, ethnicity, language barriers) affect health outcomes of the “most vulnerable:”– Demographic characteristics (e.g., average age, gender, ethnicity,

language barriers, health literacy, socioeconomic status)

MOC includes a description of the most vulnerable members specifically:Factor 3• Draw a correlation between demographic characteristics

and clinical requirements:- Specify how the characteristics adversely affect health status &

outcomes and the need for unique clinical intervention

MOC 1 Element B: Most Vulnerable Beneficiaries- Factor 3

Factor 4• Establish relationships with community partners

– Describe the process for partnering with community providers to deliver needed services:• Type of specialized resources and services

• How the SNP facilitates member/caregiver access

• How the SNP guarantees provision of continuity of eligible services

True/False

When an organization describes the demographic characteristics of its most vulnerable

beneficiaries, the unique clinical interventions that address those needs do not have to correlate

to the identified characteristics.

Polling Question

Questions

MOC 2: Care Coordination

Brett Kay

Intent: Describe admin/clinical staff roles and responsibilities

–Focus: • How care coordination (e.g. health care needs, preferences and sharing information across health care staff and facilities) occurs

• All elements must address the SNP’s care coordination activities in detail

MOC 2: Element A: SNP Staff Structure

Factor 1: Describe the administrative staff roles, responsibilities, and oversight functions.

– Identify & describe employed or contracted staff that perform administrative functions:• Enrollment and eligibility verification

• Claims processing

• Administrative oversight

Factor 2: Describe the clinical staff roles, responsibilities and oversight functions

– Identify & describe employed or contracted staff that perform clinical functions including:• Directing beneficiary care & education

• Care coordination

• Pharmacy consultation

• Behavioral health counseling

• Clinical oversight (e.g., describe how license/competency verification relates to specific population being served)

Factor 3: Coordination of responsibilities and job title

–Describe how identified staff responsibilities coordinate with job title e.g. impact of staff changes:• Title or position

• Levels of accountability

Factor 4: Contingency plan– Identify & describe contingency plans to ensure

continuity of staff functions.

MOC 2: Element A: SNP Staff Structure-Factor 4

Factor 5: Initial & annual MOC training– Describe the process for conducting initial & annual

MOC training• Training content & strategies

• Employed & contracted staff*

*Contracted staff do not include physicians or other providers

Factor 6: Maintaining training records• Describe how the plan documents & maintains

training records:– Process for documenting completion of required

training; and

– How/where the Plan maintains training records

Factor 7: Corrective actions:• Describe the actions taken if staff do not

complete required MOC training– Explain challenges to completing training for

employed and contracted staff

– Actions taken for missed or deficient training

Polling Question

When an organization describes its contingency plan(s) to avoid disruption, what types of information can be included?

a)Disaster plansb)Remote/tele-work plansc) Technical issue plansd)Staff departure/turnover planse)All of the above

Intent: Describe how the HRAT collects and uses data to assess medical, functional, cognitive, psychosocial and mental health needs of members.• Focus:

– How the HRAT is used to develop the ICP– Dissemination of information to ICT– Process for conducting the initial and annual

assessments– Methodology used to review, analyze and stratify HRA

results

MOC 2: Element B: Health Risk Assessment Tool

Factor 1: Describe the use and dissemination of HRAT information:• Describe the data collected:

– Medical– Functional– Cognitive– Psychosocial; and – Mental health needs of members

• Process for developing and updating the ICP in a timely basis

MOC 2: Element B: Health Risk Assessment Tool-

Factor 1

Factor 2: Disseminating HRAT information• Describe the process for sharing HRAT information with the

ICT• ICT use of HRAT information

– Integration of results into the ICP

Factor 3: Initial HRA & annual reassessment• Describe the process including:

– Timeframe for conducting (e.g. initial & annual)– Methodology (mailed, in-person, phone interview)– Contacting members not responding to mailings or calls

MOC 2: Element B: Health Risk Assessment Tool-Factors

Factor 4: Plan & rationale • Describe the process used to review, analyze and

stratify HRAT results– Detail stratification process– Communication of stratification results:

• ICT• Provider network (e.g. specialty providers, allied or behavioral health

practitioners)• Members/caregivers; other SNP personnel as applicable

– Explain how the SNP uses results to improve care coordination

MOC 2: Element B: Health Risk Assessment Tool-Factor 4

Intent: Describe how the ICP is developed and communicated• Focus

– Describing the essential elements of the ICP – Detail the process for development/modification – Identify staff responsible – How updates to the ICP are:

• Documented• Maintained; and • Communicated.

MOC 2: Element C: Individualized Care Plan (ICP)

Factor 1: ICP essential components• Description includes:

– Member’s self management goals & objectives– Personal health care preferences– Services specifically tailored to beneficiary’s needs

MOC 2: Element C: Individualized Care Plan (ICP)-Factor 1

Description includes:• Factor 2: ICP development process & staff responsible

– Process for ICP development– Details staff responsible e.g. role & functions, professional

requirements and credentials

• Factor 3– Personnel responsible for development of ICP, including

involvement of member/caregiver

MOC 2: Element C: Individualized Care Plan (ICP)-Factors 2 & 3

• Factor 4– Process for determining the frequency for review &

modification when changes occur

• Factor 5– Communication of updates and modifications to the

MOC 2: Element C: Individualized Care Plan (ICP)-Factors 4 &

Polling Question

True/False

When the organization develops an ICP for each beneficiary to deliver appropriate care, it must

ensure that the member and/or caregiver is involved in the creation of the ICP.

Intent: Describe the key components of the ICT• Focus:

– Key members of ICT – Roles/responsibilities – How the ICT contributes to improving beneficiary

health status – Communications within the ICT

MOC 2: Element D: Interdisciplinary Care Team (ICT)

Factor 1: ICT membership• Description includes:

– How the SNP determines key members of ICT e.g., specialized expertise requirements

– Process for facilitating participation of beneficiary/caregiver

– Use of member HRAT results & ICP to identify ICT membership

– Explain how ICT uses health care outcomes to evaluate established processes

MOC 2: Element D: Interdisciplinary Care Team (ICT)-Factor 1

Factors 2 & 3: ICT Roles & responsibilities• Description includes:

– Use of clinical managers, case managers & others to provide interdisciplinary care

– How the SNP includes member/caregiver in the process

– Provision of needed resources– How the SNP facilitates member/caregiver access to

ICT members

MOC 2: Element D: Interdisciplinary Care Team (ICT)-Factors 2 &

Factor 4: Communication plan• Description includes:

– Evidence of an established communication plan– Process for maintaining effective and ongoing communication– Verification of communication e.g. ICT meeting minutes, ICP

documentation– Communication with members identified with challenges e.g.

hearing impairments, language barriers or cognitive deficiencies

MOC 2: Element D: Interdisciplinary Care Team (ICT)-Factor 4

Intent: Describe the SNP’s processes to coordinate care transitions and facilitate timely communications across settings and providers. • Focus:

– Factor 1: The process for coordinating transitions– Factor 2: Personnel responsible for coordination efforts– Factor 3: Description of coordination between settings during a care

transition– Factor 4: How beneficiaries have access to personal health information to

facilitate communication with providers– Factor 5: Education provided to members/caregivers to manage conditions

and avoid transitions– Factor 6: Process used to notify members/caregivers of staff assigned to

support member through transitions

MOC 2: Element E: Care Transition Protocols

Factor 1: Process for coordinating transitions• The description must specify:

– Process & rationale used to connect members with appropriate providers

• Factor 2: Personnel responsible for coordination efforts– Identify & describe staff responsible for:

• Coordinating care transition process• Ensuring follow-up services, e.g., scheduling appointments,

needed resources

MOC 2: Element E: Care Transition Protocols-Factors 1 & 2

Factor 3: Applicable transitions• Description of the steps staff managing transitions

take before, during & after transitions

Factor 4: Access to health information • Process for facilitating member/caregiver access to

health information necessary to communicate with providers in other healthcare settings or outside the network.

Factor 5: Self-management activities• Education provided to members/caregivers to manage

conditions and avoid transitions– Signs & symptoms of worsening condition– How to respond to changes

Factor 6: Notification of point of contact • Process used to notify members/caregivers of staff

assigned to support member through transitions

Questions

SNP ApprovalModel of Care Training

Elements 3

Nidhi Dalwadi Mehta

55SNP Approval MOC Training: Elements 3-4, January 2015

• Element A: Specialized Expertise– Intent: demonstrate how the network is

designed to address the needs of the SNP’s target population

– Focus:• Plan-level information for the provider network

MOC 3: Provider Network-Element A

• Factor 1: The specialized expertise in the provider network addresses the needs of the target population (MOC 1)

• Factor 2: Oversees the licensure and certification of providers

• Factor 3: Documentation of provider information• Factor 4: Collaboration between the providers

and ICT to provide necessary specialized services

Element A: Specialized Expertise

True/False

The specialized expertise in the provider network must address the needs of the SNPs target

population identified in MOC 1.

Polling Question

• Element B: Use of Clinical Practice Guidelines (CPGs) and Care Transitions Protocols– Intent: Describe how the SNP ensures that

beneficiaries receive appropriate, evidence-based care and services

– Focus:• Population-level decision making, not individual clinician

level• Identify challenges to using CPGs and protocols

MOC 3: Provider Network

• Factor 1: Monitoring how providers utilize CPG and nationally-recognized protocols appropriately

• Factor 2: Identify challenges where CPG and protocols need to be modified

• Factor 3: Decisions to modify CPGs and acted upon by the ICT

• Factor 4: Oversees the use of care transition protocols to maintain continuity of care

Element B: Use of CPGs and Care Transition Protocols

• Element C: Provider Network Training– Intent: describe how the SNP provides training for

its provider network– Focus:

• How SNPs make training available to all network providers

MOC 3: Provider Network-Element C

• Factor 1: Initial and annual trainings for network and out-of-network providers seen by members on a routine basis

• Factor 2: Offering MOC trainings to all network providers

Element C: MOC Training for the Provider Network-Factors 1 & 2

• Factor 3: Challenges associated with completion of MOC trainings

• Factor 4: Actions taken when training is not complete

Element C: MOC Training for the Provider Network-Factors 3 & 4

True/False

A plan must show that all providers have received training on its MOC.

Polling Question

Questions

SNP ApprovalModel of Care Training

Elements 4

Nidhi DalwadiSandra Jones

• Element A: Quality Performance Improvement Plan– Intent: Describe how the SNP conducts quality

improvement related to its overall MOC– Highlights:

• Plan-level information focusing on goals that measure overall plan performance related to all aspects of the MOC

MOC 4: MOC Quality Measurement & Performance Improvement

• Factor 1: Overall quality improvement plan as it relates to the MOC and how the organization provides appropriate services to SNP beneficiaries, based on their unique needs

• Factor 2: Specific data sources used to continuously analyze, evaluate and report MOC quality performance

Element A: MOC Quality Performance Improvement Plan-

Factors 1 & 2

• Factor 3: Key personnel involved with the internal quality performance process (e.g., Leadership, management groups, other SNP personnel and other stakeholders)

• Factor 4: SNP-specific goals and health outcomes objectives are integrated into the overall plan (described in MOC 4, Element B)

Element A: MOC Quality Performance Improvement Plan-

Factors 3 & 4

• Element B: Measureable Goals– Intent: identify and define the measureable

goals/health outcomes for the target population, and how the SNP determines if goals are being met

– Highlights• Plan-level measures and goals for the target population• Focus is on health/clinical goals (e.g., controlling diabetes,

mental health screening)

MOC 4: MOC Quality Measurement & Performance Improvement-

Element B

The organization must identify and define measureable goals and health outcomes for the MOC and: • Factor 1: How they are utilized to improve the health

care needs of SNP beneficiaries.

• Factor 2: Describe how health outcome measures evaluate the overall SNP population health outcomes at the plan level.

Element B: Identify Goals and Health Outcome Measures-Factors

• Factor 3: Describe how the SNP establishes methods to assess and track the MOCs impact on SNP beneficiaries’ health outcomes.

• Factor 4: Describe the processes and procedures the SNP will use to determine if health outcome goals are met.

• Factor 5: Describe the steps the SNP will take if goals are not met in the expected time frame.

Element B: Track and Assess Goals

True/False

Measureable goals from Element A and B can be the same as long as the plans provide details

related to its unique target population.

Polling Question

• Element C: Measuring Patient Experience– Intent: describe how the SNP measures beneficiary

satisfaction and responds to results– Focus

• Plans may use wide variety of patient experience/satisfaction surveys—CAHPS/HOS are acceptable, as are other alternatives

• Provide details of surveys and methodology for data collection

MOC 4C: MOC Quality Measurement & Performance Improvement

The organization’s MOC must address the process for measuring SNP member satisfaction by:

• Factor 1: Describing the specific SNP survey used.

• Factor 2: Explaining the rationale for the selection of a specific tool.

Factors 1 & 2: SNP Survey Utilization

• Factor 3: Describe how results of patient experience surveys are integrated into the overall MOC performance improvement plan.

• Factor 4: Describe steps taken by the SNP to address issues identified in survey responses.

Factors 3 & 4: Integration and Identification of Issues

• Element D: Ongoing Performance Improvement Evaluation of the MOC– Intent: Describe how the SNP uses the results from

its performance indicators/measures to support its ongoing quality improvement plan

– Focus• Include lessons learned and challenges in obtaining

timely data.

MOC 4 Element D: MOC Quality Measurement & Performance

Improvement

• Factor 1: How the organization will use the results of the quality performance indicators and measures to support ongoing improvement of the MOC.

• Factor 2: How the organization will use the results of the quality performance indicators and measures to continually assess and evaluate quality.

Factors 1 & 2: Quality Performance Indicators and

Measures

• Factor 3: The organization’s ability for timely improvement of mechanisms for interpreting and responding to lessons learned through the MOC performance evaluation.

• Factor 4: How the performance improvement evaluation of the MOC will be documented and shared with key stakeholders.

Factors 3 & 4: Lessons Learned and Key Stakeholders

• Element E: Dissemination of SNP Quality Performance– Intent: describe how the SNP communicates its

quality improvement plan/performance to stakeholders

– Focus• Detail who receives the information, how often they

receive it, and what communication methods are used

MOC 4 Element E: MOC Quality Measurement & Performance

Improvement

The organization must address the process for communicating its quality improvement performance by:• Describing how performance results and other

pertinent information are shared with multiple stakeholders.

Factor 1: Communication with Stakeholders

• Factor 2: Stating the scheduled frequency of communications with stakeholders.

• Factor 3: Describing the methods for ad hoc communication with stakeholders.

Factors 2 & 3: Frequency and

Ad-hoc Communication

• Identifying the individuals responsible for communicating performance updates in a timely manner.

Factor 4: Responsible Individuals

83CMS – NCQA SNP Approval MOC RequirementsContract Year 2014

QUESTIONS

SURVEYOR/EXECUTIVE REVIEWERS What you need to know

Important to Know

• Surveyor ResourcesOnline and/or in Resource Guide include:– Policies &

Procedures

– Review Checklist

– Expense Forms

– MOC Requirements & Scoring Guidelines

– FAQs

– Examples of submission responses

• Surveyor Assignments−Pre-assigned

−Number assigned according to total plans submitting and FT/PT availability

−Subject to change post submission

−May vary during Cure #1

Performing Reviews• ISS User ID & Password requiredo Instructions --see screenshots

o Retrieve MOC from Document Library

o Score tools per Guidelines (make changes as necessary; no changes to Initial Review scores of “4” during Cure 1)

o Remember to click “Save” and “Results”

o Address questions to Sandra or Nidhi

o Notify snpapproval@ncqa.org of any issues that may arise and upon completion of assignment

What to Expect• Documentation

– Ranges from minimal to significant– May not address all requirements; do

not give full credit

• Examples– CMS no longer requires a case study

or examples

– Responses must include a detailed description of “the what” & “the how”

Textbox LanguageSurveyors and ERs:• Please use clear & concise language as Plans

will see the comments

• Keep comments brief; AND

• Provide enough detail for Plan to understand why it does not meet the requirements

• After Cure – if score changes to a 4, place comments in internal notes & include the following: “Documentation submitted during the Cure meets the requirements.”

• Do not use the following characters: ; & < >

Scoring Requirements

• Scoring Consistency– Assign same score for plans with tools from

same Org w/same documentation

Questions

Additional Resources• NCQA SNP Approval Webpage:

http://www.ncqa.org/snpapprovalsurveyor

• SNP Approval mailboxsnpapproval@ncqa.org

• Available resources:– CY 2015 MOC Scoring Guidelines– 2014 Surveyor Resource Guide (Updated with

Examples)– Surveyor Checklist– Expense Report– FAQs – Conflict of Interest Form

Training & EducationSurveyor Training (repeat)

oFebruary 9, 2015 1:00-3:00pm EToWeekly Q&A Calls

oMarch 5, 12, 19, & 26Dial-In Information: 1-866-505-4013

(Confirmation Code): 370 852 5392#*When it asks if you are the leader you will do

nothing and then you will be placed into the call.

--SNP Technical Assistance Calls 3-4:30pm ET

o April 23 Dial-In Information: 866-628-7188Conference ID: 403 895 20

Training• Surveyor Training – Repeat

Monday, February 9, 2015 -- 1-3:00 pm ET

WebEx Information:Dial-In Information:• 1-866-505-4013• (Confirmation Code): 370 852 5392#*When it asks if you are the leader, wait for placement into the call.

WebEx Information:Event address for attendees:• https://ncqaevents.webex.com/ncqaevents

Event password: Approval2015

ContactsBrett KayAssistant Vice President, Recognition Operations202-955-1722kay@ncqa.org

Casandra MonroeDirector, Accreditation Operations202-955-5136monroe@ncqa.org

Sandra JonesAssistant Director, Accreditation Operations202-955-5189jones@ncqa.org

Contacts

Nidhi DalwadiAccreditation Manager202-955- 3585dalwadi@ncqa.org

Delia PonceSurvey Management Analyst202-955-1742ponce@ncqa.org

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