Special Needs Plan Model of Care

2017

© 2017 Chinese Community Health Plan

• Special Needs Plan (SNP) Goals• CCHP Dual Eligible SNP• Enrollment & Eligibility• Vulnerable Beneficiaries• Additional Benefits• Provider Network• Member Centered Care• Care Coordination Staff Structure• Care Coordination Activities• Health Risk Assessment• Individualized Care Plan• Provider Statement• Interdisciplinary Care Team• Care Coordination Programs• Use of Evidence-Based Guidelines• Additional Regulatory Requirements• HEDIS

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Elements of CCHP SNP Model of Care

• SNP Model of Care (MOC) is a vital quality improvement tool and integral component for ensuring that the unique needs of each beneficiary enrolled in a SNP is identified and addressed.

• In 2010, the Patient Protection and Affordable Care Act (ACA) reinforced the importance of the MOC as a fundamental component of SNP quality improvement by requiring the National Committee for Quality Assurance (NCQA) to execute the review and approval of SNPs’ MOC based on standards and scoring criteria.

• A SNP can be one of 3 types:§ Dual-Eligible SNP (D-SNP) for members eligible for Medicare and

Medicaid.§ Chronic SNP (C-SNP) for members with severe or disabling chronic

conditions -initial and annual attestation (that member has condition) is required from provider.

§ Institutional SNP (I-SNP) for members requiring an institutional level of care or equivalent living in the community.

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What is SNP Model of Care?

• Improve access to medical, mental health, and social services.

• Improve access to affordable care.• Improve coordination of care through an identified

point of contact.• Improve transitions of care across health care

settings, providers and health services.• Improve access to and utilization of preventive

health services.• Improve member health outcomes.• Assure appropriate utilization of services.

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Special Needs Plan Goals

• CCHP has a D-SNP with only 1 product: Senior Select Plan

• Senior Select Plan§ Offered only in San Francisco§ 100% of members have Medicare and Medicaid

benefits§ Current membership is 3,053 members§ 95% ethnically Chinese§ 93% speak primarily Chinese, as reported to the

Centers for Medicare and Medicaid Services (CMS).

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CCHP Dual Eligible SNP

• CCHP receives enrollment applications directly from sales agent.

• CCHP Enrollment and Eligibility Department reviews the application and checks eligibility for Medicare and Medicaid benefits.

• For existing CCHP Medicare beneficiaries that become eligible for Medi-Cal benefits, the beneficiary will have to initiate coordination of Medicare and Medi-Cal benefits.

• When Medicare beneficiaries obtain Medi-Cal eligibility, the beneficiary is encouraged to join the SNP plan.

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Enrollment & Eligibility

• Special needs plan population are at highest risk of poor health outcomes.

• Most are low-income and socioeconomic status, frail with multiple chronic and acute health problems that are often complicated by language access, poor diet, non-compliance with medication and treatment plan, infrequent medical attention, and faulty or absent medical equipment.

• The SNP program is designed to enhance members’ health and address access issues that arise as a result of language, illiteracy, mobility and cultural barriers.

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Vulnerable Beneficiaries

• $0 cost for medical services• 24 taxi rides (one-way) for medically-related trips

(e.g., home to outpatient office visits; home to laboratory)• Access to a network of optometrists,

ophthalmologists and vision services through VSP• Access to a network of dentists through Delta

Dental• Annual health risk assessments• Annual individualized care plans

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Additional Benefits for Senior Select

In addition, the Senior Select Coordinator and Care Coordination Social Workers provide translation, referrals, application assistance, and liaison for beneficiaries to community resources such as:

§ In-Home Support Services§ Meals on Wheels§ San Francisco Paratransit § Chinese Newcomer Programs§ CCHP Member Services § CCHP Case Management§ CCHP Pharmacy§ San Francisco Legal Aid§ Community-Based Long-Term Case Management Services

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Additional Benefits for Senior Select…cont.

• CCHP maintains a comprehensive network of primary care physicians, specialists and non-physician practitioners to meet the health needs of chronically ill, frail and disabled SNP members.

• Most providers speak Chinese and are culturally and linguistically capable to care for the CCHP SNP members.

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Provider Network

• The Member:§ Is informed of and consents to receive calls from

Care Coordination team.§ Is given the option to opt out of receiving calls but

Care Coordinator will continue to make attempts, at a minimum annually or when there is a change in health status.

§ Participates in the development of an Individualized Care Plan (ICP) by completing their initial or annual Health Risk Assessment (HRA).

§ Participates in the Interdisciplinary Care Team (ICT) through communication with the Care Coordinator.

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Member Centered Model of Care

• All staff are trained on the SNP MOC initially upon hire and annually:§ Coordinators are non-clinical administrative staff that help beneficiaries

coordinate access to services. § Social Workers help beneficiaries with psychosocial issues access low-

income utility programs, community resources, housing programs and appointments with network and out of network social workers, psychologist, psychiatrists and other mental health services.

§ Nurses help beneficiaries with their acute care post-discharge needs, disease and case management and health education.

• QI Manager, UM Manager and Director of Clinical Services is ultimately responsible for ensuring implementation and communication of the SNP MOC including annual training, updates and maintenance training for providers.

• The Medical Director is responsible for overseeing all administrative performance and care delivery services to ensure the highest possible quality of care for all beneficiaries.

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Care Coordination Staff Structure

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• Performs an assessment of medical, psychosocial, cognitive, functional, and mental health needs and status

• Develops a comprehensive individualized care plan

• Identifies barriers to goals and strategies to address

• Provides personalized education for optimal wellness

• Encourages preventive care

• Reviews and educates on medication regimen

• Promotes appropriate utilization of benefits

• Assists member to access community resources

• Assists caregiver when member is unable to participate

• Provides a single point of contact during care transition

Care Coordination Activities

• The self-reported health risk assessment (HRA) survey includes questions on medical, psychosocial, cognitive, functional and mental health.

• New enrollees are sent the initial HRA and given 90 calendar days to complete it and subsequently reassessed annually.

• If the HRA is not received within one (1) month, at minimum 4 attempts are made to complete the HRA telephonically.

• After 4 unsuccessful attempts, an unable to reach letter is sent to inform the member of CCHP’s multiple attempts to reach the member.

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Health Risk Assessment

HRA Sample

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• Responses to the HRA are used to develop and/or update the member’s individualized care plan (ICP).

• ICP includes:v Goals and Objectivesv Member’s health care preferences v Self-management plans and goalsv Description of services tailored to member’s needsv Identify if goals met or not met

• CCHP uses evidence-based Milliman Care Guidelines (MCG) to develop the ICP.

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Individualized Care Plan

• A copy of the member’s ICP is sent to the member and his/her primary care provider (PCP).

• The ICP is updated when there is a change in the member’s health status or at a minimum annually.

• ICP updates and changes are communicated to the member, caregiver(s) and primary care provider.

• Members that do not respond to the HRA will still receive an ICP.

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Individualized Care Plan…cont.

• Claims and pharmacy data are used to help develop the member’s ICP when they do not respond to the HRA.

• Evaluates data to improve HCCs and quality scores.

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HRA

Rx

CLAIMS

OCR

ICD 10HCC’s

ICD 10HCC’s

ICP

ICP

ICP

Individualized Care Plan…cont.

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ICP Sample

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• Providers are asked to sign and return the Physician Care Plan Signature page to Care Coordination department if they agree with the care plan.

• If the provider does not sign and return the signature page in two (2) weeks the care plan is considered accepted.

ICP Provider Statement

• The Interdisciplinary Care Team (ICT) meets regularly to discuss and evaluate care coordination issues, quality of care issues and complex case management as needed.

• Composition of the interdisciplinary care team (ICT) is dependent on the member’s need as determined by the HRA and ICP.

• The ICT may include the CCHP Medical Director, Nurses, Social Workers, Director of Clinical Services, UM Manager, the member, members’ providers, pharmacists, etc.

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Interdisciplinary Care Team

• All CCHP members are eligible for Care Coordination programs which include the Post Discharge Program, Disease and Case Management services.

• The Disease Management program focuses on the top 4 conditions:§ Heart Failure (CHF)§ Chronic Obstructive Pulmonary Disease (COPD)§ Diabetes§ End Stage Renal Disease (ESRD)

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Care Coordination Program

• Members are at increased risk of adverse outcomes when transitioning from one care setting to another such as admission or discharge from a hospital, skilled nursing, rehabilitation center or home health.

• When the member is discharged home, the Care Coordinators conduct post-discharge calls within 1 business day of discharge to review changes to the member’s care plan, assist with discharge needs, review medications and encourage follow-up care with primary care physician and specialists within 5 days of discharge.

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Care Transition: Post-Discharge Program

• CCHP uses evidence-based guidelines§ All current care plans and member education

materials were developed using MCG (formerly Milliman Care Guidelines)

§ Additional resources include Hayes, Inc., Centers for Medicare and Medicaid Services (CMS), and Agency for Healthcare Research and Quality and Healthwise.

§ Member education materials are reviewed annually to ensure consistency with clinical practice guidelines.

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Use of Evidence-Based Guidelines

• CCHP conducts initial and annual MOC training for its employed and contracted staff. Contracted staff includes staff from medical groups that help CCHP implement the SNP Model of Care.

• Provider network initial and annual training is conducted by CCHP or its medical groups; only providers that serve the SNP population are required to complete the MOC training.

• The CCHP SNP must also go through the CMS – NCQA approval process which scores each of the clinical and non-clinical elements of the MOC. SNPs are approved for one, two, or three year periods – CCHP SNP was approved for three (3) years.

• Annual submission of HEDIS measures for the SNP (Senior Select) population

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Additional Regulatory Requirements

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• Colorectal Cancer Screening

• Management of COPD Exacerbation

• Controlling High Blood Pressure

• Persistence of Beta-Blockers after Heart Attack

• Osteoporosis Management Older Women with Fracture

• All Cause Readmission• Antidepressant Medication

Management

SNP HEDIS Measures

• Follow Up after Hospitalization for Mental Illness

• Annual Monitoring for Persistent Medications

• Potentially Harmful Drug Disease Interactions

• Use of High Risk Medications in Elderly

• Care for Older Adults• Medication Reconciliation

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• New enrollees of Covered California will receive an initial health risk assessment (HRA).

• The self-reported HRA survey will include questions on member demographics, medical, psychosocial, cognitive, functional and mental health.

• Responses to the HRA will be used to develop and/or update the member’s individualized care plan (ICP).

Plans for Covered California

• Centers for Medicare and Medicaid (CMS) requires Medicare Advantage organizations like CCHP to forward attestations to their first tier entities to complete on an annual or more frequent basis.

• Compliance requires certification and attestation of:§ SNP MOC Training§ General Compliance Training§ Fraud, Waste, Abuse Training§ Screen for Excluded Individuals§ Compliance with Medicare Law§ Data Accuracy§ Availability of Records

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Attestation Requirements

After you have completed the training module, please print this page. Read and sign this Attestation Statement and return to CCHP Care Coordination via fax at 415-955-8815.

I acknowledge that I have completed the 2017 SNP MOC Provider Training.

_______________________Print Name

_______________________ ______________Signature Date Completed

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Training Attestation

Questions

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THANK YOU