Special Needs Plan (SNP) Model of Care Training MOC Training... · The SNP MOC is a working...

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Special Needs Plan (SNP) Model of Care Training April 2018


Presenters

Lisa Roth MS, Vice President Care Coordination

• [email protected]

Maureen Mello MS-HCM, Senior Project Manager


Lisa Desai MBA, Manager Care Coordination


Robi Hellman RN, MSN, CNS, Director of Education and Training


Maricris Tengco RN, BSN, PHN, MHCA, Director Care Coordination


Jeanette Despal MPH, RN, CCM, Manager of Complex Care


Adalinda Gutierrez RN, BSN, PHN, Network Compliance Manager – Clinical



Accreditation Statement

RN: SCAN Health Plan (SCAN) is a provider approved by the

California Board of Registered Nursing (Provider #CEP-13453).

This activity has been approved for up to 2 contact hour(s).

BBS: Course meets the qualifications for 2 hours of continuing

education credit for LMFTs, LCSWs, LPCCs, and/or LEPs as

required by the California Board of Behavioral Sciences. SCAN

Health Plan is a CAMFT-approved continuing education provider.

Provider No. 127226


Questions from the Audience


Learning Objectives

Learning Objectives

1. Special

Needs Plan Overview

2. CMS Special Needs Plan

Model of Care Requirements

3. CMS Audit Readiness

4. Resources

and Reference Materials


Our Mission

SCAN Health Plan (SCAN) is the nation’s fourth largest not-for-profit

Medicare Advantage (MA) plan, serving over 180,000 members in

California.

SCAN’s mission is to keep seniors healthy and independent. We do

this is by providing comprehensive medical coverage, prescription

benefits, and support services specifically designed to meet the

unique needs of seniors.


Special Needs Plan Overview: Background

The Medicare Prescription Drug, Improvement, and

Modernization Act of 2003 (MMA) authorized the

creation of a type of Medicare Advantage (MA) plan

referred to as a Special Needs Plan (SNP), to address

the unique needs of certain Medicare populations.

Improvements for Patients and

Providers Act of 2008 (MIPPA)

contained provisions for

reauthorizing and modifying SNPs.

Patient Protection and Affordable Care

Act (PPACA – effective 01/01/2012)

contained provisions reauthorizing

and modifying SNPS.

All Special Needs Plans became

permanent in 2018 with the signing

of H.R. 1982, the “Bipartisan

Budget Act of 2018”.

2003 2012

2008 2018


Special Needs Plan Overview: Goals

Improve member health outcomes

Ensure appropriate utilization of services for preventative health and chronic conditions

Enhance care transitions across all healthcare settings

Improve coordination of care and ensure appropriate delivery

of services through the alignment of the HRA, ICP and ICT

Improve access and affordability to member healthcare needs


Chronic

Special Needs Plan

(C-SNP)

Special Needs Plan Overview: Types of SNPs and Eligibility

1

Eligibility verified 30 days post enrollment

• Balance Plan: Diabetes

• Heart First Plan: CHF, Arrhythmia, CAD, PVD,

Chronic Venous Thromboembolic Disorder

• VillageHealth Plan: ESRD

Eligibility verified monthly

• Designed for members who have both Medicare Part A

and Part B, Full Medicaid benefits and FIDE SNP

• Connections and Connections at Home Plan

Eligibility verified by outside vendor

• Meet state criteria for Nursing Facility Level of Care

(NFLOC)

• Healthy at Home Plan - Must reside in the community

and not a facility (I-SNP is Institutional-Equivalent)

Fully Integrated Dual

Eligible Special Needs Plan

(FIDE-SNP/D-SNP)2

Institutional

Special Needs Plan

(I-SNP)3


SNP Model of Care (MOC)

Model of Care (MOC): CMS requires SNP Plans to develop a MOC

that describes their approach to caring for their target population.

The SNP MOC is a working framework on how the SNP proposes

to coordinate the care of the SNP enrollees.

Required Training: CMS requires all employed and contracted staff,

who provide direct and indirect care coordination services to SNP

members, to complete initial SNP MOC training and annually

thereafter. SCAN delegates this requirement to each medical group

to provide initial and annual training for all employed and contracted

staff and maintain the documentation of that training.

For more information, please refer to your Delineation of Responsibilities (DOR)


SNP Model of Care (MOC): Requirements

MOC 1

• SNP Population

MOC 2

• Care Coordination

MOC 3

• Provider Network

MOC 4

• Audit Readiness


SNP Model of Care (MOC): Process

CMS allows MA plans to file for

3 types of SNPs (I-SNP, D-SNP,

C-SNP)

In February Plans are

required to submit a MOC

to CMS for approval

In April Plans are notified of MOC scores (must receive 70% to pass)

In January plans implement their approved MOC


30%

11%47%

0%6%

6%

C-SNP Balance

D-SNP Connections at Home

D-SNP Connections

I-SNP

C-SNP Heart First

C-SNP ESRD

MOC 1: SCAN’s SNP Population – Overall


MOC 1: SCAN’s SNP Population – SNPs by County

Plan Name Type of Product LA OC RV SB SD MA NAP/SON

Heart First Chronic SNP X X X X X X

Balance Chronic SNP X X X X

VillageHealth Chronic SNP X X X X

Healthy at

HomeInstitutional SNP X X X X

Connections

at HomeDual SNP X X X

FIDE SNP Dual SNP X X X


MOC 1: SCAN’s SNP Population – Characteristics

Characteristics Summary

Demographic SCAN SNP members are more ethnically diverse than the general Medicare population.

General healthSCAN SNP members were more likely to view their health as fair or poor when compared

to the Medicare population (35% v. 27%).

DepressionEight percent (8%) of the SCAN SNP members had a positive depression screen, compared

to 13% of the Medicare population.

PainAbout 16% of the SCAN SNP members and Medicare population reported that pain interfered

with their day to day activities quite a bit/very much/all the time.

Chronic Conditions71% of the SCAN SNP members, 85% of the H5425 all SNP members, and 76% of the

Medicare population reported having two or more chronic conditions.

Activities of

Daily Living

Eighteen percent (18%) of SCAN SNP members have 3 or more activities of daily living (ADL)

impairment; compared to 14% among the Medicare population.

Urinary/Bladder

Problems

Over a third of the SCAN SNP members aged 85 or above reported urinary or bladder

problems in the past 6 months.

Falls About 28% of the SCAN SNP members reported falling to the ground within the past year.


MOC 2: Care Coordination – Requirements

Health Risk Assessment

(HRA)

All SNP Members must have an Initial

and Annual Reassessment

Individualized Care Plan (ICP)

All SNP Members must

have a care plan based on results

of HRA

Interdisciplinary Care Team

(ICT)

All SNP Members must have

interdisciplinary care

Care Transitions

(CT)


MOC 2: Care Coordination – Process

Assess needs at enrollment and annually

(HRA)

Individualized (ICP that includes issues

identified in HRA)

Review for Care

Management, if Triggers

Provide Interdisciplinary

Care Team Approach

Revise Care Plans

Joint Delegate and

SCAN Responsibility

SCAN Responsibility


MOC 2: Care Coordination – Responsibilities

SCAN Health Plan Delegated Medical Group

DX Verification (C-SNP) Review & Act on Trigger Reports

HRA and Care Plan (Initial & Annual)* Provide CM, Interdisciplinary Care & CT*

Provide Weekly Trigger Reports Submit CT Reports Quarterly*

Provide Tools & Resources For those in CM, Update Care Plan*

* Village Health Responsibility for ESRD


MOC 2: Care Coordination – Health Risk Assessment (HRA)

Key Learning Objectives:

How the HRA is used to guide care for the member

How we use the HRA to create the Individualized Care Plan (ICP)

How HRA data is used to analyze and risk stratify the SNP Membership


MOC 2: Care Coordination

*https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/mc86c05.pdf (page 22)

How the organizations use the HRAT to

develop

and update members’ individualized care plan

Use and dissemination of special needs plans

health risk assessment tool

(HRAT) information.

1.

2.

How the organizations disseminate the HRAT

information to the interdisciplinary care teams

and how the teams use that informationUse and dissemination of HRAT

information.

3. Initial HRAT and annual reassessment. How the organizations conduct the initial HRAT

and annual reassessment for member

4.The detailed plan and rationale for reviewing,

analyzing and stratifying (if applicable) the HRAT

result*

Plan and rationale.

Health Risk Assessment (HRA) – CMS Guidelines



SCAN is responsible for the Diagnosis Verification (C-SNP) and HRA for

all SNP Plans

SCAN doesn’t delegate the HRA process

Contact includes telephonic outreach and mail, including an HRA form

for the member to complete and return by mail

Outreach consists of five attempts to contact member

Other SCAN assessments meet the requirement of an HRA (I-

SNP/NFLOC)

Health Risk Assessment (HRA) – SCAN Process



The HRA addresses Medical, Functional, Psychosocial, Mental Health

and Cognitive domains

SCAN conducts an HRA initially and annually (within 365 days of

previous) for all SNP members

Screen SNP members for care coordination, complex care management

and long-term services and supports (LTSS – D-SNP)

Health Risk Assessment (HRA) – SCAN Process



≈≈

≈≈

“Poor” self-rated health3+ SNF admissions

in the last year

Difficulty with ADLs –

(Bathing, Eating & Toileting)

3 + ER visits in the

last year

Moderate to Severe

Depression (PHQ-2)

Report difficulty

managing health condition

8 or more medications

3 + Falls in the last year

3 + hospital admissions

in the last year

Requests a Case

Manager/RN

Health Risk Assessment (HRA) – Triggers


Polling Question – Health Risk Assessment (HRA)

Which of the following current HRA triggers do you think is the best

indicator of high risk?

a) “Poor” self-rated health

b) Moderate to Severe Depression (PHQ-2)

c) ADL Deficits

d) 3 or more falls in the past year

e) Reported difficulty managing health conditions



Health Risk Assessment (HRA) – Trigger Report



Delegated entities are required to access and retrieve the HRAs, care plans and

trigger reports within seven calendar days of posting on SCAN’s SNP sftp site.

Delegated provider partners are required to do the following within 30 calendar days

of receiving the trigger reports (i.e., 30 calendar days from the date they were posted

on SNP sftp site):

• Access, review and document the date the trigger reports were reviewed:

– Trigger reports will indicate the date of assessment.

– Trigger reports are sent to provider organizations the following Monday

(post assessment). Calculate 30 days (one month) from that Monday.

• Documentation of the clinical review of the files and outreach attempts:

– Minimum of three separate daily attempts within a seven-day timeframe.

Health Risk Assessment (HRA) – Medical Group Expectation



Address care management trigger reasons by analyzing findings from the HRA and

other assessments and inputs and document the following:

• If unable to reach members or members decline to participate, follow organization

protocol to complete the activities based on information available in the

organization’s system and update the documentation.

• Document next steps/plan of care going forward (sent letter, etc.).

Were members enrolled in care management? If not, document reason.

ICT documentation for all SNP members that triggers regardless of the level of acuity:

• If ICT collaboration not required, is there documentation indicating why not?

Health Risk Assessment (HRA) – Medical Group Expectation


Polling Question – Health Risk Assessment (HRA)

Which of the following do you think should be added as an HRA

trigger?a) Housing or financial issues

b) Difficulty maintaining a caregiver/caregiver burnout

c) Possible physical, emotional or financial abuse

d) Does not have an Advanced Directive/POLST

e) Difficulty taking medications as prescribed


MOC 2: Care Coordination - Individualized Care Plans (ICP)

Key learning Objectives:

Create and implement consistent processes for ICPs which include all required

elements per CMS

Develop SMART Goals for all patients

Ensure communication of the ICP to all stakeholders

Identify and document to all components of an individualized care plan



*https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/mc86c05.pdf (page 23)

The elements necessary to implement the ICPICP essential components.1.

2.The process to develop the ICP, including how often

the ICP is modified as members’ healthcare needs

change

ICP development process and personnel.

3. ICP development process and personnel.The personnel responsible for development of the

ICP, including how members and/or caregivers are

involved

4.How the ICP is documented, updated and where it is

maintainedICP documentation and maintenance.

Individualized Care Plans (ICP) – CMS Guidelines

5.How updates and modifications to the ICP are

communicated to members and other stakeholders*Updates and modifications.



ICP is developed following the completion of the initial health risk assessment (HRA)

upon the members’ enrollment and updated with each discharge from a facility or a

change in health status.

The ICP includes any triggers identified during the HRA process, any concerns voiced

by members during the HRA process and/or specific concerns members would like to

address with their primary care physician.

The ICP is a dynamic document that’s updated at least annually; it may be changed

more frequently if there is a change in the members’ needs.

The finalized ICP is shared via mail or electronically with members, primary care

physicians and other members of the ICT at the provider organization and elsewhere.

Individualized Care Plans (ICP) – SCAN Process



Identification of measurable goals, including prioritized goals that consider the

members’ and caregivers’ goals, preferences and desired level of involvement

in the care management plan.

• Measurable goals include the current status, progress to meeting the goal

and the desired outcome.

Address all documented triggers with goals on the ICP.

Documentation shows review and revision of the ICP as changes in health status,

function and psychosocial needs are identified (does the documentation address

the member issues?).

There is evidence of communication of ICP and revisions to members and primary

care physicians (was care plan sent to members and primary care physicians?).

ICT recommendations are documented in the care plan.

Individualized Care Plans (ICP) – Medical Group Expectation


MOC 2: Individualized Care Plans (ICP) – Case Study

Member presents with the following triggers

on the HRA.

T2DM

Inability to manage medications related to

DM

Medications:

Metformin 500 mg BID

Simvastatin 40 mg qD

Lisinopril 20 mg qD

HCTZ 25 mg qD

Omeprazole 20 mg BID

Gabapentin 600 mg TID

What should be

documented on the care

plan?

Please type in at least one

thing in the chat box that

should be documented

and why.


MOC 2: Individualized Care Plans (ICP) – Case Study

Concerns Responsible

Person

Actions Frequency Goals

Difficulty managing

diabetes

You, your family,

your doctor

Talk to your doctor about a referral to an

Endocrinologist

As needed Keep diabetes well

managed

Having symptoms such

as numbness, pain,

burning, or tingling

You, your family,

your doctor

Talk to your doctor about any pain or

concerns and ask about treatment options

At your next

appointment

Manage your diabetes

symptoms

How do I manage my foot

care

You, your family,

your doctor

Talk to your doctor about getting a foot

doctor referral

Annually Maintain healthy feet

My medication You, your family,

your doctor

• Take all medications as prescribed

• Bring all medications with you to your

next doctor visit

• Do not stop taking any medication before

talking to your doctor or pharmacist

As needed Take medication as

ordered by the doctor to

maintain health

Medication refill barriers You, your family,

your doctor

• Ask your pharmacy about delivery

options

• Call SCAN Member Services for 90 day

supply option or transportation resources

• Talk to your pharmacy about refilling your

medication all at once

• Ask your pharmacy about auto-refill

As needed Have access to all my

medications


Polling Question - Individualized Care Plans (ICP)

1) When should an individualized care plan be written or revised?

a) After completing the HRA with the member

b) When discussing the health care concerns with the patient

c) Following discharge from a facility

d) If the patient raises health concerns

e) All of the above


Polling Question - Individualized Care Plans (ICP)

2) What are the components of an individualized care plan?

a) Measurable goal for each trigger

b) Individualized goals (after discussing with member)

c) Specific triggers and health concerns listed

d) Actions for the member to meet that goal

e) All of the above



*https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/mc86c05.pdf (page 25-26)

How the organizations determine the composition of ICT

membershipICT membership.1.

2.

How the roles and responsibilities of the ICT members (including

members and/or caregivers) contribute to the development and

implementation of an effective interdisciplinary care process ICT member roles and responsibilities.

3. ICT member roles and responsibilities. How ICT members contribute to improving the health status

of SNP members

4.How the SNPs regularly exchange member information

within the ICT, including evidence of ongoing information

exchange*

Communication plan.

Interdisciplinary Care Team (ICT) – CMS Guidelines



Interdisciplinary Care Team (ICT) – Participants

ICT Participants

Care Managers

Care Coordinators

PCP/ Specialist

Other Health Professionals

Member/ Caregiver

Medical Director At minimum collaboration between

any of the following:

• CM assigned

• Care Coordinator

• Medical Expert (PCP/Specialist)

• Member/Caregiver


Polling Question – ICT

1) Who are required to have MOC training?

a) Case Managers only

b) Medical Directors only

c) All ICT Participants except Specialists

d) a & b

e) All ICT Participants



Interdisciplinary Care Team (ICT) – SCAN Process

ICT Documentation (within 30 calendar days from the trigger report posted date on SCAN SNP sftp site)

All members requires ICT (including Failed Contact or Declined)

Internal CCM or MG (based on delegation agreement)

HRA Triggers/ Referrals from SCAN ICT**

HRA Completed

**Non-triggers: Clinical Review will be completed by SCAN


MOC 2: Interdisciplinary Care Team (ICT) – Case Study

Mrs. Emma Moyer, 78 years old presents with the

following triggers on the HRA.

3 ER Visits and 3 Falls in the last year

Medications:

Flexeril 5 mg 3x a day (muscle relaxant) prescribed

by pain specialist

Simvastatin 40 mg qhs

Lisinopril 20 mg once a day for BP

Promethazine 25 mg prn for nausea

Amitriptyline 20 mg 2x a day for back pain

prescribed by PCP

Vidodin 5-325 mg 3x a day prn for back pain

prescribed by ER pain specialist

Received HRA Trigger on

3/12/18 and assigned to

CM on 3/16/18

Trigger and HRA reviewed

by the assigned case

manager on 3/19/18

Attempted to contact the

member on 3/19, 3/22, 3/26

but unsuccessful, sent

unable to reach letter on

3/27


Polling Question – ICT

1) As the assigned case manager what do you need to do?

a) Close the case since it is a failed contact

b) Send review to pharmacist & fax results to PCP 3/28/18

c) Send the updated ICP to the member & PCP on 3/30/18

d) Both b & c

e) Present to IDT on 5/19/18



Interdisciplinary Care Team (ICT) – eg, ICT Collaboration Note



All triggered SNP members and SNP members received thru referral process need to have an

ICT completed regardless of the acuity level

Provide documentation to demonstrate that all ICT participants were offered and

completed SNP model of care training.

Minimum ICT composition: collaboration between any of the following:

• CM assigned to member

• Care coordinator

• Medical expert (primary care physician, specialist, etc.)

• Include members/caregivers if available

Interactions and collaborations can occur in person, telephonically or electronically.

Interdisciplinary Care Team (ICT) – Medical Group Expectation



ICT documentation should be completed for all triggered members, regardless of the acuity

level, within 30 calendar days from the trigger report posted date on SCAN SNP sftp site.

ICT documentation must include evidence of the following:

• Date of the ICT collaboration

• List of all the ICT participants (including all the recommended providers)

• Interventions

• Evidence that a copy of care plan was provided to/is made available to ICT participants and

members.

Interdisciplinary Care Team (ICT) – Medical Group Expectation



*https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/mc86c05.pdf (page 26-27)

How the organizations use care transition protocols

to maintain continuity of care for SNP Members.Continuity of care.1.

2.The personnel responsible for coordinating the care

transition processCare transition personnel.

3. Applicable transitions.Transfer elements of the members’ individual care

plans between healthcare settings

4.Member access to personal health information to facilitate

communication with providers in other healthcare settingsBeneficiary personal health information.

Care Transitions (CT) – CMS Guidelines

5.How members and/or caregivers are educated about health

status to foster appropriate self-management activitiesSelf-management activities.

6.How members and/or caregivers are informed about

the point of contact throughout the transition process*Notification of point of contact.



Based on the “Care Transitions” model developed by Eric Coleman, MD.

Medication self-management and reconciliation across care settings

How and when to respond to warning signs/symptoms (Red Flags)

Ensuring post discharge MD follow up visits occur

A Personal Health Record (PHR) to convey information across settings

Advanced care planning to assist in end of life discussion and

decision-making

Care Transitions (CT) – SCAN Process



Documentation indicating members were contacted (or attempts made) within three

business days post- notification of discharge from one setting to another

Documentation notifying primary care physicians within three business days from

discharge

Evidence that care is provided by appropriate persons

Evidence that care plan transferred between healthcare settings before, during and after

a transition of care

Evidence members coached regarding care transitions

Care Transition (CT) – Medical Group Expectation



Documentation in the care management system that members of the ICT and the

members/caregivers have access to the plan of care

Submit care transition logs (ICE) to SCAN SNP sftp on a quarterly basis:

• Follow the industry collaboration effort template

• SCAN provides oversight to ensure regulatory and compliance requirements are

met

Care Transition (CT) – Medical Group Expectation



SNP SFTP Operations

SNP Report Job ScheduleDay of the Week

Report is Sent

Completed HRA

and Care PlansWeekly Saturdays

Trigger Reports Weekly Mondays

SNP Census Monthly 2nd of Month


MOC 3: Provider Network

•ACSA

•Advanced Directives

•Preventive Screening Guidelines

•CHF

•COPD

•Diabetes

•Hypertension

•Falls

•Dementia

Care Management

Disease Management

CareTransitions

Care Coordination


MOC 3: Provider Network

Who

• Staff/Providers delivering the care to SNP members must complete SNP MOC training annually

Format

• Written materials, face-to-face, web, audio/video conference

Content

• Use your own, or draw from SCAN’s

https://www.scanhealthplan.com/providers/clinical-guidelines-and-practice-tools/snp-model-of-care-training

http://www.scanhealthplan.com/provider-tools/


MOC 4: Audit Readiness

Annual Delegation Oversight Audit

• The Network Compliance Team audits the medical group’s who are responsible

for SNP care management

• SCAN also has internal controls and audits to ensure compliance (on the plan side)

CMS MOC Compliance Audit

• The CMS Program audit if the SNP MOC evaluates implementation and

performance

• CMS Audit cycles generally run about 4 years

Delegation Oversight Audit



DO Network Compliance Auditors – Clinical review files to ensure compliance in four

critical areas. Lack of evidence in any of these areas result in a corrective action plan.

This is predominately done through File Review vs. P&P review

Trigger Report

• Documentation to demonstrate the trigger report reviewed w/in 30 days of receipt

Care Transitions

• Documentation indicating member was contacted/attempted w/in 3 business days of

notification of discharge?

SNP Care Management

• Documentation of a clinical care management plan and an updated ICP

• ICT recommendations documented and incorporated in the care

MOC Training

• Evidence MOC Training was offered to employees and providers w/in the last 12 months

Delegation Oversight Audit



The purpose of the CMS SNP audit is to evaluate the implementation of the SNP Model of Care (MOC)

Enrollment Verification (SCAN Responsibility)• I-SNP (Institutional)

– Must meet Nursing Facility Level of Care (NFLOC)

– Initial eligibility is verified by a vendor and annual eligibility is verified by Care Manager

• D-SNP (Dual Eligible)

– Must have Medicare and Medi-Cal and the eligibility is verified monthly

• C-SNP (Chronic)

– Qualifying diagnosis verified 30 days post enrollment

HRA, CP, ICT (Joint Responsibility)• HRAs – Timely HRAs are completed to assess members’ medical, psychosocial, cognitive, functional

and mental health needs

• ICPs – These include measurable goals and outcomes that will be reviewed and revised for members

enrolled in CM

• ICT – Documentation includes recommendations from participants and a list of participants with their

roles. All the ICT participants are required to have SNP Model of Care Training.

CMS Audit



Plan Performance (Joint Responsibility)• Plan Performance is reported through SCAN’s Annual SNP Evaluation Process. This report consist

of methodology for collecting, analyzing, reporting and evaluating the MOC’s performance

• Plan Performance is also evaluated through Annual SNP Audit

• The analysis of performance measures will be used to improve the MOC and develop Corrective

Action Plans

CMS Audit


CMS and SCAN SNP Resources

SCAN Health Plan Website


CMS and SCAN SNP Resources

CMS Website

Medicare Managed Care Manual Chapter 5

Medicare Managed Care Manual Chapter 16b

https://www.cms.gov

Questions

THANK YOU!

Special Needs Plan (SNP) Model of Care Training MOC Training... · The SNP MOC is a working...

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