Special Needs Plans Model of Care Training 2012. Special Needs Plan Special Needs Plans (SNPs) were created by Congress in the Medicare Modernization.

Special Needs PlansModel of Care Training

2012

Special Needs Plan

Special Needs Plans (SNPs) were created by Congress in the Medicare Modernization Act (MMA) of 2003 as a new type of Medicare managed care plan focused on certain vulnerable groups of Medicare beneficiaries: the institutionalized, dual-eligibles and beneficiaries with severe or disabling chronic conditions. These beneficiaries are typically older, with multiple comorbid conditions, and thus are more challenging and costly to treat.

MHP Special Needs Plan’s

Two types of SNP’s that MHP offers to its members:

• Medica HealthCare Plans MedicareMax Plus (PSO SNP) for individuals with Dual eligible for Medicare and Medicaid

• Medica HealthCare Plans MedicareMax Chronic Care (PSO SNP) for individuals with severe or disabling chronic conditions such as diabetes and/or cardiovascular disorders, to include cardiac arrhythmias, coronary artery disease, peripheral vascular disease, and chronic venous thromboembolic disorder

SNP Course Overview

• The Centers for Medicare and Medicaid (CMS) require all contracted medical providers to receive basic training about the Special Needs Plans (SNP) Model of Care.

• The SNP Model of Care (MOC) is the plan for delivering coordinated care and case management to special needs members.

• This course will describe how MHP and its contracted providers can work together to successfully deliver the SNP MOC.

SNP Learning Objectives

After the training, attendees will be able to :

• Describe the basic components of MHP’s SNP Model of Care

• Explain how MHP Case Management programs work and how contracted providers will work with the Case Management programs

• Describe essential role of contracted providers in delivering the SNP MOC.

What is the SNP MOC?

Is the plan for delivering case management and services for Medicare

Advantage members with special Needs. It establishes guidelines for:

• Assessment and case management for members• Communication among members, caregivers, and

providers• Use of an Interdisciplinary Care Team (ICT) of health

professionals• Participation of Primary Care Physician (PCP)• Measurement of individual and program outcome• Every SNP member is evaluated annually with a

Health Risk Assessment

Model of Care ElementsThe Model of Care is a service delivery mechanism that

contains thefollowing 11 elements:

1)Targeted Population2)Measurable Goals3)Staff Structure and Roles4)Interdisciplinary Care Team (ICT)5)Provider Network6)Model of Care Training7)Health Risk Assessment (HRA)8)Individualized Care Plan9)Communication10)Care Management of the Most Vulnerable Population11)Performance and Health Outcome Management

What is the scope of our Model of Care ?

Looking for improvement opportunities: Managing the process of care transitions, identifying problems that

could cause transitions, and where possible preventing unplanned transitions

Identifying unplanned transitions, analyzing data to help prevent unplanned transitions and identifying members at risk of unplanned transitions

Ensuring safe transitions from initial to final destination

Evidenced-based clinical practice guidelines

Helping members obtain the services they need regardless of the payer, by coordinating Medicare and Medicaid benefits for members

Identifying and assisting those members with changes in their Medicaid eligibility

SNP Targeted Population

This element describes the members identified for SNP participation based on

their needs and qualifications. For MHP these are dual-eligible (D-SNP) members

and/or members with chronic disease (D-SNP). These members may havecomplex medical needs, but they also have increased psychosocial needs to

thatimpact compliance with care plans and health outcomes.

Medica HealthCare Plans MedicareMax Plus (D-SNP) for individuals with Dual eligible for Medicare and Medicaid benefits and services

Medica HealthCare Plans MedicareMax Chronic Care (C-SNP) for individuals with severe or disabling chronic conditions such as diabetes and/or cardiovascular disorders, to include cardiac arrhythmias, coronary artery disease, peripheral vascular disease, and chronic venous thromboembolic disorder

SNP Model of care Goals

Improve access to care to medical, mental health, pharmacy and social services

Improving access to affordable care

Improve access to preventive health services

Improve coordination of care through an identified point of contact • i.e. PCP or Specialist

Assure appropriate utilization of services

Provide seamless transition of care

Assure cost-effective service delivery

SNP Staff Structure RolesAdministrative Staff:• Process enrollment and

verify eligibility for SNP’s• Process claims and facilitates

resolution of grievances and providers complaints

• Collect, analyze, report and act on performance and health outcome data

• Conducting quality improvement activities

• Review and analyze communication data

• Report to CMS and states

Communicate Plan

information

Management Staff:• Monitors MOC implementation

and evaluate its effectiveness• Assure licensure and competency;

statutory and regulatory compliance

• Monitor contractual services• Monitors ITC• Assures timely and appropriate

delivery of services, seamless transitions and timely follow ups

• Assures providers use clinical practices guidelines

Interdisciplinary Care Team (ICT) The ICT is composed of several key clinical disciplines,

including: The MHP SNPs have an appropriate medical team with clearly defined

roles. The team provides the infrastructure necessary to coordinate the plan

of care and provide appropriate staff and program oversight:

• The Medical Director and/or his physician delegate• Case and Disease Managers• Social worker• The plan’s delegated behavioral health provider• The beneficiaries PCP (if applicable)• The beneficiary and/or their designated advocate or caregiver (if

possible)

SNP Provider network

• Providers with specialized expertise:• Primary Care Physicians• Multi specialty Providers • Behavioral Health Providers• Nursing Professionals• Network facilities

The provider network offers broad practitioner representation from the medical,

diagnostic and treatment areas with the specialized expertise to care for Special

needs members.

Model of Care TrainingAll internal personnel and contracted providers are trained on the Model of Care. All employees that have responsibilities for services provided to SNP enrollees receive training as part of their new employee orientation.

They are provided with an electronic copy of a Power Point presentation to review initially and they are also given a SNP-MOC Training Manual that they can refer to after the initial training is completed. All internal employees also receive MOC update training annually.

What is an HRA? HRA is a Health Risk Assessment . This tool has questions that

addresses several areas pertinent for the evaluation of medical, functional, cognitive and psychological problems in order to have a complete picture of the patients needs

The interview is done via telephone and in the event that the patient does not respond and after three attempts then the form is sent via mail with a postage paid envelope. The initial Risk Assessment is being done within the first 90 days after enrollment and within 1 year of last HRA

The reassessment is done annually, or sooner, if it is determined that there may have been a change in the member’s condition.

What is an Individualized Care Plan (ICP)?

The member/care giver, case manager and providers are involved with short and long term goal settings, interventions and the identification of barriers for each of the problem areas.

Individualized care plans are generated by the Case Manager for those members willing to participate, based on the members/care giver’s answers to assessment questions.

Communication Network

MHP has many differentCommunication

methodologies.The methods for internal communications are:

• Face-to-face meetings• E-mail systems• Quarterly Internal

Newsletter

MHP uses variouscommunication vehicles to disseminate information to

its network of providers, such

as:

• Quarterly provider newsletters

• Fax blasts•Mailed announcements and /or educational material• Face-to-face meetings

Most Vulnerable Beneficiaries

MHP defines its most vulnerable population and outlines specific

interventions for these members. Most vulnerable beneficiaries are:

Frail and/or disabled individualsBeneficiaries developing end–stage renal disease after

enrollmentBeneficiaries near to end of lifeBeneficiaries having multiple or complex chronic

conditions

Performance & Health Outcome Measurement Goals

Monitor coordinator of care through the PCP: This goal focuses on the compliance of the member visiting the PCP at least quarterly, to assure the implementation and follow up on the care plan.

Assure seamless transitions and timely follow-ups: This goal focuses on the timeliness and appropriateness of post-discharge coordination of care. The goal is to follow-up all members within 7 days of hospital discharge.

Ensure access to preventative care services: Monitors HEDIS prevention and screening measure results. This goal focuses on the access to preventive care services. These services are accessed thru the coordination of care based on HRA and case management assessment.

Special Needs Structure & Process Measures Evaluation: Monitor s annual results and recommendations and corrective action plans if applicable.

Evaluate measurable health outcomes and implementation of interventions: Monitor s measure outcomes submitted to QA Committee, HEDIS, CAPHS and HOS results as described in General Preventative Outcomes Measures .

For More Information

A complete version of MHP Model of Care is available at www.medicaplans.com

Questions, Contact the Case Management Department at [email protected]

Thank You