Training for CarePoint Health Plans Staff

A CarePoint Medicare Advantage and I-SNP training presentation

CarePoint Health Plans is an insurance company that shares ownership with Bayonne Medical Center, Christ Hospital and Hoboken University Medical Center

CarePoint is currently licensed in Hudson County

CarePoint Health Plans has a contract with the Centers for Medicare and Medicaid Services (CMS) to offer an MAPD plan and an I-SNP plan

A Medicare Advantage plan combines traditional Medicare A & B

Medicare Advantage (or Part C) is managed careMedicare

The coverage is provided by a private (non-governmental) insurance company

Anyone who has Medicare A & B, lives in the coverage area, and does NOT have End-Stage Renal Disease is also eligible for a Medicare Advantage plan

Medicare Advantage plans are usually offered with Part D (prescription drug) coverage as well and are known as MAPD plans.

Prescription drugs are covered under Medicare Part D

Most Medicare Advantage plans include prescription drug coverage under Part D – if the plan offers Part D, a member must get their coverage under it

A Medicare Advantage plan that offers Part D is called an MAPD plan

A Special Needs Plan is a Medicare plan that limits enrollment to members with specific diseases or characteristics and tailors benefits to best meet their needs

An I-SNP is an Institutional Special Needs Plan This is a Medicare managed care plan for individuals

who, for 90 days or longer, have had or are expected to need LTC SNF, LTC NF, SNF/NF, ICF/MR or inpatient psychiatric level of care. Individuals in the community may be enrolled if they also require the institutional level of care.

I-SNP eligibility must be verified independently, using the State-approved assessment tool, such as the PASRR, OASIS, MDS, and documentation from the individual’s physician.

Premiums and benefits differ between CarePoint’s MAPD and I-SNP.◦ CarePoint Advantage (MAPD PPO) $0 additional

premium (still pay Part B premium)

◦ CarePoint Guardian (I-SNP PPO) $37 monthly premium

Refer to the Summary of Benefits and Evidence of Coverage for differences between traditional Medicare, CarePoint Advantage and CarePoint Guardian

Imperative to adhere to all CMS Marketing Guidelines

Potential members MUST request an appointment – NO REFERRALS and NO SOLICITATION

Potential members may be identified:◦ At Sales & Marketing and Educational events◦ By approaching a clearly-identified Sales & Marketing

representative◦ By contacting a Sales & Marketing representative as a

result of seeing approved marketing material or at the suggestion of another individual

◦ I-SNP eligibility MUST be verified BEFORE a Sales & Marketing meeting can be scheduled with the individual

A Medicare Advantage plan can be either an HMO or a PPO – currently, CarePoint’s plans are PPOs

The Primary Care Physician must be in-network in both types of plans

Both HMO and PPO must have appropriate access to primary care and specialists in-network

“Network Adequacy” includes: number and specialty of providers, distance and travel time to providers within the community the Plan serves

Provider network includes primary care and specialist physicians, mid-level providers, allied health practitioners, tertiary care facilities, lab, x-ray, home health, transportation and others

Often, additional providers are contracted for services not available within the network (example: transplant surgery, cardiac surgery)

Occasionally an out-of-network provider may be contracted for a single patient and/or a single case

All network providers are subject to the Plan’s Credentialing process and Quality measures and,

All staff and providers will participate in orientation to this model of care on a yearly basis

In an HMO the member receives all care in-network, and referrals are usually required

In a PPO the member may go out-of-network for care – the cost-sharing is usually higher. For CarePoint Advantage the member has a 30% cost-share for most out-of-network services

PPOs do not require referrals

In both types of plans approval, also known as Prior Authorization, for certain types of tests is often required (example: CT scans, MRI, endoscopy)

Improve care through:◦ Improving access to care

Network primary care and specialty physicians including Behavioral Health

Assess health care needs and respond

Access to additional resources

Maintenance of health care coverage

◦ Improving coordination of care

Utilize care managers, nurse practitioners

Provide clear explanation of available benefits and how to access

Provide care that is coordinated across settings

Improve member health with best practice preventive health services

Make certain members receive:◦ The right care

◦ In the right setting

◦ In the right amount

◦ At the right time

◦ For the right member

Monitor member health and provider practices to assure improvement in positive health outcomes

Owned by the same owners as the hospitals

Administrative staff roles and responsibilities◦ Executive management

◦ Provider network and relations

◦ Compliance

◦ Finance

◦ Sales & Marketing

◦ Customer service

◦ Claims payment

◦ Information technology

◦ Human resources

Clinical staff roles and responsibilities◦ Chief medical officer

◦ Director of Quality

◦ Director of Care Management

Case & Disease Management

Utilization review

◦ Appeals and Grievances

◦ Pharmacy management

Patient care is provided primarily by CarePoint’s network of providers

Members receive care across the entire spectrum of settings, from outpatient to observation, inpatient, rehabilitation and skilled nursing facility.

Because a Medicare Advantage plan is offered by a managed care organization, care is coordinated for the member in all settings.

Care coordination is accomplished using a variety of resources:◦ Physicians and other providers◦ Care and Case Managers◦ Mid-level providers (e.g. nurse practitioners)◦ Nurses◦ Discharge planners◦ Home health care agencies◦ Social workers◦ Area Agencies on Aging◦ Community- and faith-based organizations◦ Others

Communication◦ A critical component of the coordination of care

◦ Include all stakeholders

◦ Coordinate care between member, family, members of care team

◦ Provide information using multiple forms of media including mail, e-mail, Web, member and provider portals, phone, fax, face to face meetings, video conferencing, member handbook, member newsletter, provider manual, information packages, provider profiles, policies & procedures, inter-disciplinary care team meetings

CarePoint provides a robust IT care management system to track:◦ Member health◦ Quality of care◦ Member plans of care◦ Medical/surgical, behavioral, radiology, laboratory and pharmacy

encounter and claims information◦ Metrics to support the above measures plus HEDIS and others

Information is shared with members of the integrated health care system to improve:◦ Quality of care◦ Access to care◦ Overall health outcomes◦ Efficiency◦ Productivity

Guided by the members’ health status, CarePoint may provide management in the form of:◦ Automated information provided by mail, e-mail or

phone◦ Individualized information provided by phone by a care

manager◦ Personalized visits by a mid-level provider

This information may relate to a member’s:◦ Medications◦ Upcoming appointments for provider visits, testing or

procedures◦ Prescription order updates◦ Recommendations for health care management.

Priorities

Member centered

Provider driven

Focused on Best Practices, both clinical and managerial

Patient Centered Care Manage care across the continuum using◦ Primary Care Physicians◦ Mid-level providers◦ Coordinate community-based/faith-based services◦ Leverage additional resources

Pro-actively manage population and individual care◦ Identify care needs and gaps in care early and

intervene before the member’s condition worsens

Focus on the member/family experience

All members (MAPD & I-SNP) will complete a Health Risk Assessment (HRA) upon enrollment; assistance will be provided to those who are unable to do this on their own

The HRA will be incorporated in the Plan’s medical management system to generate a Clinical Risk Assessment

This Clinical Risk Assessment will be used by the Plan to provide the most appropriate care management resources for the member

As additional diagnostic and pharmacy data is obtained about the member, this clinical risk assessment will be refined using the Johns Hopkins ACG System

The Health Risk Assessment contains questions regarding◦ Family history◦ Personal health status◦ Activities of daily living (ADLs)◦ Medications◦ Use of/Need for special services◦ Use of preventive services◦ Pain◦ Fear of falling◦ Mental health and cognitive function◦ Nutrition/Exercise/Health habits◦ Tobacco/Substance use and abuse◦ Social supports◦ Quality of life

Clinical Risk Assessment◦ Medical Care Management staff at CarePoint will use the

information to: Create a Plan of Care based on nationally-accepted Clinical

Practice Guidelines and coordinate this Plan of Care with the member’s primary care physicians

Analyze the member’s care history to identify gaps in care and upcoming needs (barriers to care and interventions)

Determine appropriate care management tools for member –phone calls, written material by mail, e-mail reminders, assignment of mid-level provider for members at higher risk

Members must be given the option to not participate in care management – the Plan will continue to monitor their health status and they may opt-in at any time

Member engagement will be promoted with a variety of methods including:

Motivational interviewing (“What’s important to you? What would it mean to you to get it? What would it mean if you didn’t?”)

Direct contact from Care Management staff

Culturally appropriate health information available in a variety of media

Incentives when legally permissible and appropriate

Empower practitioners ◦ Information on best practices

◦ Identification of gaps in care

◦ Objective data on individual practice versus peers

◦ Provide clinical management tools

◦ Emphasis on preventive care

Member

Physician

Preventive HealthAcute & Chronic CareRehabLTCEnd of Life Care

Mid-Level Providers (NP)

Deploy across continuum of care

Improve access to care

Refer members to Primary Care Physician office

Provide efficient, evidence-based care

Enhance provider-member engagement, communication and productivity

Coordinate resources

Member

Physician

Mid-Level Provider (NP)

Timely Access to Care

Care Coordination

Early Warning

Clinical Risk Management

Agency on Aging

Social Services

CBO/FBO

The I-SNP Model of Care introduces additional resources to care for institutionalized and institutional-equivalent members, and most importantly, those most vulnerable (multiple chronic conditions and/or medications, dual diagnosis, end of life) identified by Care Management and the team of practitioners◦ Inter-Disciplinary Care Team◦ INTERACT II care management method and tools◦ Enhanced care coordination

Inter-Disciplinary Care Team (IDCT)◦ All I-SNP members will have an IDCT comprising

representatives of the coordinated care team

◦ New members of the IDCT will be included to address developments in the member’s care needs

◦ Member and family participation is actively encouraged. Invitations and meeting summary letters are sent

◦ The IDCT meets regularly, updates the Plan of Care as necessary, and may additionally meet should there be a change in condition of the member

◦ Best-Practice care will be coordinated, and will include the use of IT infrastructure and prior-authorization

Additional components of model of care◦ Care providers use INTERACT II

Empowers everyone in the institution to improve the quality of care

Clinical and educational tools and strategies to manage changes in resident condition

Improve quality with early identification, assessment, documentation and communication

Resources to manage end of life care as well

Examples of INTERACT II clinical tools follow:

STOP AND WATCH and the SBAR documentation tool

INTERACT Early Warning Tool – STOP AND WATCH Seems different than usual Talks or communicates less than usual Overall needs more help than usual Participated in activities less than usual

Ate less than usual (Not because of dislike of food)

N Drank less than usual

Weight change

Agitated or nervous more than usual Tired, weak, confused, or drowsy Change in skin color or condition Help with walking, transferring, toileting more than usual

INTERACT II “PROGRESS NOTE” - SBAR Physician/NP/PA Communication and Progress Note For New Symptoms, Signs and Other Changes in Condition Before Calling MD/NP/PA: Evaluate the resident and complete the SBAR form (use

“N/A” for not applicable) Check VS: BP, pulse, respiratory rate, temperature, pulse

ox, and/or finger stick glucose if indicated Review chart: recent progress notes, labs, orders Review relevant INTERACT II Care Path or Acute Change

in Status File Card Have relevant information available when reporting (i.e.

resident chart, vital signs, advanced directives such as DNR and other care limiting orders, allergies, medication list)

SBAR DETAILS S SITUATION

The symptom/sign/change I’m calling about is _______________________________________________________

____________________________________________________________________________________________

This started___________________________________________________________________________________

This has gotten (circle one) worse/better/stayed the same since it started

Things that make the condition worse are ___________________________________________________________

Things that make the condition better are ___________________________________________________________

Other things that have occurred with this change are __________________________________________________

B BACKGROUND

Primary diagnosis and/or reason resident is at the nursing home _________________________________________

Pertinent history (e.g. recent falls,fever, decreased intake, pain, SOB, other) ________________________________

_____________________________________________________________________________________________

Vital signs BP_________/__________ HR ________________ RR ________________ Temp ________________

Pulse Oximetry ____________% On RA___________on O2 at ______________L/min via___________ (NC, mask)

Change in function or mobility ____________________________________________________________________

Medication changes or new orders in the last two weeks _______________________________________________

Mental status changes (e.g. confusion/agitation/lethargy) ______________________________________________

GI/GU changes (circle) (e.g. nausea/vomiting/diarrhea/impaction/distension/decreased urinary output/other)

Pain level/location ______________________________________________________________________________

Change in intake/hydration _______________________________________________________________________

Change in skin or wound status ___________________________________________________________________

Labs ________________________________________________________________________________________

Advance directives (circle) (Full code, DNR, DNI, DNH, other, not documented)

Allergies __________________________________ Any other data ______________________________________

A ASSESSMENT (RN) OR APPEARANCE (LPN)

(For RNs): What do you think is going on with the resident? (e.g. cardiac, infection, respiratory, urinary, dehydration,

mental status change?) I think that the problem may be ____________________________________________-OR

I am not sure of what the problem is, but there had been an acute change in condition.

(For LPNs): The resident appears (e.g. SOB, in pain, more confused) _____________________________________

R REQUEST

I suggest or request (check all that apply):

Provider visit (MD/NP/PA) Monitor vital signs and observe

Lab work, x-rays, EKG, other tests Change in current orders _______________________

IV or SC fluids New orders __________________________________

Other (specify) ________________________ Transfer to the hospital

Staff name ____________________________________________________________________________RN/LPN

Reported to: Name ____________________________(MD/NP/PA) Date____/____/____ Time________a.m./p.m.

If to MD/NP/PA, communicated by: Phone In person

Resident name _______________________________________________________________________________

INTERACT II tools at the bedside for early identification & assessment

Care Paths◦ Dehydration

◦ Fever

◦ Mental status change

◦ Symptoms of CHF

◦ Symptoms of lower respiratory tract infection

◦ Symptoms of UTI

Value-added benefits◦ Nursing facilities will have free WiFi, resident e-

mail, Internet café

◦ Wanderguard ® - to identify individuals who have wandered from allowed areas

◦ Delayed egress magnetic locking doors – to prevent elopement

◦ Pet therapy

◦ Video-conferencing for members and their families

Care Transitions◦ Members in MAPD & I-SNP will be managed across

the continuum of care

◦ Mid-level providers will manage transitions with the members’ physicians to assure continuity of care, medication reconciliation, and adherence to the Plan of Care

Member Member Member

Nursing Facility

Community Acute Care Facility

Mid-Level Provider

Mid-Level Provider

Mid-Level Provider

Plan of Care

Bi-directional exchange of information

Expanded population stratification

Pro-active care management and gap analysis

Analytics

Robust clinical metrics◦ Based on HEDIS/NCQA -> 5-Star

◦ Provider profiling and appropriate corrective action

Member

Physician

Mid-Level Provider (NP)

CarePoint Health Plans

EducationBest PracticesMetrics

Predictive ModelingRisk StratificationCare Management

Empowerment

Education

Healthier Members

Healthier Population

Improved Care Experience

Efficient, High-Quality, Cost-Effective Care

Quality – Making sure we’re doing it right! MAPD & I-SNP Quality Management Steering

Committee◦ Supported by:

Medical Care Management Committee Medical Standards Committee Grievance & Appeal Committee Credentialing Committee Pharmacy & Therapeutics Committee

◦ Coordinated with Compliance Committee

Quality indicators measure process and outcomes of care.

Quality indicators, overall and by provider, will be monitored, tracked and trended and compared to benchmarks and goals.

Indicators and Goals:◦ Provider Access Standards – 90% for all providers◦ Appointment Availability Standards – 90% for all providers◦ % of members who selected a PCP◦ % of MDS completed in 30 days – 100%◦ % of Plans of care completed within 5 days of transition –

100%◦ % of members who received flu and pneumovax vaccine –

increase by 5-10%◦ HEDIS® Effectiveness of Care measures – meet 50th

percentile of NCQA◦ % of avoidable re-admissions – reduce by 3-5%◦ % of inappropriate ER utilization – reduce by 3-5%◦ Rate of falls – reduce rate of falls with injuries 1-2%◦ Rate of decubitus ulcers – reduce by 2%◦ Rate of quality of care complaints – reduce by 2%

Please download and print the following statement, sign and date, and return it to CarePoint. Thank you.CarePoint MOC attestation

Questions?

David J. Sand, MD, MBA, FACS◦ Chief Medical Officer, CarePoint Health Plans◦ Phone: 201-432-2133 ext. 106◦ E-mail: [email protected]