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SNP Approval Model of Care Training Elements 1-2 January 21, 2014 2:00 – 4:00PM EST

Brett Kay, NCQA Sus an Radke, CMS Sandra Jones, NCQA. SNP Approval Model of Care Training Elements 1-2 January 21, 2014 2:00 – 4:00PM EST. Objectives of SNP MOC Scoring Guidelines. Revise structure of the MOC to help plans better understand and meet the requirements

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SNP Approval Model of Care Training Elements 1-2 January 21, 2014 2:00 – 4:00PM EST

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  1. Brett Kay, NCQA Susan Radke, CMS Sandra Jones, NCQA SNP Approval Model of Care Training Elements 1-2January 21, 2014 2:00 – 4:00PM EST

  2. Objectives of SNP MOC Scoring Guidelines • Revise structure of the MOC to help plans better understand and meet the requirements • Model after S&P measures format • Approach familiar to the SNPs • SNPs have publicly requested such a change • Supports consistent scoring of MOCs

  3. MOC Scoring Guidelines • Used revised Appendix 1 of the MA application Model of Care Upload document—kept requirements intact, but revised formatting • Received input from stakeholders: Public Comment process • 222 comments • Health plans, trade associations, provider groups, others

  4. How will NCQA Score the MOC? • Scoring will be similar to previous years • MOC elements worth 0-4 points, based on # of factors met. • Total of 60 points (15 elements) • converted to percentage scores • E.g., 50 points = 83.33% (2-year approval)

  5. Scoring Guidelines

  6. Crosswalk to New Elements Old Elements New Elements • MOC 1: SNP Population • MOC 2: Care Coordination Care Transitions Protocol NEW! • MOC 3: Provider Network • MOC 4: Quality Measurement

  7. Project Time Line • February 25 – MA/SNP & Medicare-Medicaid Plans (MMP) Applications submitted to CMS via HPMS • March 11 –MMP application results to CMS • MA/SNP reviews continue • March 17 – CMS issues Deficiency Notices to MMPs -- Begin “Cure Process” - Plans have 7-10 calendar days to submit additional information • March 18 MMP Cure 1 TA call for Plans scoring <70%

  8. Project Time Line • March 24 Cure 1 MMP Apps due to CMS • April 28 – CMS issues Notice of Intent to Deny • April 30 – MA/SNPs & MMP TA call for Plans scoring <70% • May 8- MA/SNP & MMP Cure Apps due • May 28 – CMS issues MA/SNP Denial Notices & MMP Status Notices • June 2- SNP bids due to CMS

  9. MOC 1: Description of SNP Population Sandra Jones

  10. 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)

  11. MOC 1 Element A: Overall SNP Population 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

  12. MOC 1 Element A: Overall SNP Population Factor 2 Separated 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.

  13. MOC 1 Element A: Overall SNP Population Factor 3 Focus is on medical/health/cognitive factors* • MOC description must also include • Current health status of members • Associated behavioral health issues • Co-morbidities *Disease characteristics that could impact present status

  14. MOC 1 Element A: Overall SNP Population Factor 4 • Characteristics of population per SNP type • Includes limitations & barriers that affect overall health • C- SNP – chronic conditions, incidence & prevalence • D-SNP – Full/partial; including limitations & barriers • I-SNP –Facility type; specialty providers & services; limitations & barriers

  15. MOC 1B: MostVulnerable Beneficiaries 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 • Focus: • Important to note that the focus is on population-level, not individual members • Simply put, what makes them “different”?

  16. MOC 1 Element B: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

  17. MOC 1 Element B:Most Vulnerable Beneficiaries MOC includes a description of the most vulnerable members specifically: Factor 2 • Explain how certain characteristics (e.g. average age, gender, ethnicity, language barriers, etc.) affect health outcomes of the “most vulnerable”: • Demographic characteristics (e.g. average age, gender, ethnicity, language barriers, health literacy, socioeconomic status 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

  18. MOC 1 Element B:Most Vulnerable Beneficiaries 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 Plan facilitates member/caregiver access • Guarantee provision of continuity of eligible services

  19. QUESTIONS

  20. MOC 2: Care Coordination Brett Kay

  21. MOC 2: Element A: SNP Staff Structure 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

  22. 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

  23. MOC 2: Element A: SNP Staff Structure 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)

  24. MOC 2: Element A: SNP Staff Structure 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

  25. MOC 2: Element A: SNP Staff Structure Factor 4: Contingency plan • Identify & describe contingency plans to ensure continuity of staff functions. 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

  26. MOC 2: Element A: SNP Staff Structure Factor 6: Maintaining training records • Describe how the plans documents & maintains training records: • Process for documenting completion of required training; and • How/where the Plan maintains training records

  27. MOC 2: Element A: SNP Staff Structure 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

  28. MOC 2: Element B: Health Risk Assessment Tool 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

  29. 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

  30. MOC 2: Element B: Health Risk Assessment Tool 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

  31. MOC 2: Element B: Health Risk Assessment Tool 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

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

  33. 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

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

  35. MOC 2: Element C: Individualized Care Plan (ICP) • Factor 4 • Process for determining the frequency for review & modification when changes occur • Factor 5 • Communication of updates and modifications to the ICP

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

  37. 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

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

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

  40. MOC 2: Element E: Care Transition Protocols 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

  41. 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

  42. MOC 2: Element E: Care Transition Protocols 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.

  43. MOC 2: Element E: Care Transition Protocols 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

  44. Training & Education • Sessions focus on MOC Requirements & Technical Assistance -- MOC Elements 1 & 2 (1 training) • January 21* 2:00-4:00pm ET -- MOC Elements 3 & 4 (1 training) • January 23* 2:00-4:00pm ET -- Technical Assistance Calls 2:00 – 3:30 pm ET • February 11 • March 18 for MMP scored <70% • April 30 MA/SNPs & MMPs scored <70% * Recordings and slides available on NCQA SNP Approval website within one week of call

  45. CMS Contacts For technical inquires related to the MOC program plan requirements, appeals/denials or other issues related to the SNP/MMP approval proposal in the regulations, please contact CMS at: CMS SNP mailbox SNP_mail@cms.hhs.gov Subject line: SNP MOC Inquiry CMS MMP mailbox mmcocapsmodel@cms.hhs.gov Subject line: MMP MOC Inquiry NCQA SNP Approval Website for training recordings and slides: www.ncqa.org/snpapproval

  46. QUESTIONS

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