Special Needs Plans MODEL OF CARE TRAINING

1. 1 Special Needs PlansMODEL OF CARETRAINING Regal Medical Group

2. 2 Medicare Special Needs Plan (SNP) SNPs created by Congress in the Medicare Modernization Act in 2003 require basic training for all medical providers. New type of Medicare managed care plan focused on delivering coordinated care and case management to certain vulnerable groups: -Institutionalized -Dual-eligible -Beneficiaries with severe or disabaling chronic conditions SNP beneficiaries are typically: -Dual eligible -Older -Have multiple co-morbid conditions -More Challenging -More costly to treat

3. 3 The Focus of SNPPurpose of Model of Care Improve access to care to medical, mental health & social services Improve access to preventive health and affordable care Assure appropriate utilization of services Manage chronic conditions Improve health outcomes Help high risk beneficiaries move to lower risk continuum (transitions of care)

4. 4 Regal’s care delivery system ensures… Availability of pertinent clinical expertise and staff An Interdisciplinary Care Team consisting of the member, PCP, specialist, nurses, educators, hospice/bereavement counselor, social worker

5. 5 Evidence Based Protocols Processes of care are organized under evidence based protocols: ADA Clinical guidelines AACE Clinical Practice Guidelines California Diabetes Program ACC/AHA CHF Guidelines Ongoing stratification of risk assessment with corresponding care planning and case management Initial health risk assessment and yearly reassessment

6. 6 Care Coordination is Ongoing Telephonic care management Educational programs-mailers, Provider education, web-based information, health fairs and flu clinics Care transition coordination Social worker resources coordination & follow-up Community resources Disease management

7. 7 Roles and Responsibilities Defined roles, responsibilities and lines of communication and accountability through meetings, physician updates, care planning, care transition coordination, and compliance training

8. 8 Case Management Regular telephonic assessment Assistance with facilitating healthcare process and follow up Care Planning Care Coordination Medication Reconciliation Educational Outreach to educate on health conditions Social Services Initial & annual health risk assessments Home visit assessment Inpatient and outpatient case management Collaborate with Health Plans

9. 9 Features An individual and problem solving care plan An interdisciplinary care team A provider network with specialized expertise Clinical Practice guidelines Staff and care management roles Communication and training Performance and health outcome measurement

10. 10 Regal’s Commitment To meet the needs of vulnerable members who are frail/disabled and or near the end of life Home health assessment Hospice evaluation Care of older Adults-HEDIS measures that focuses on documentation of activities of daily living, pain status, medication reconciliation, and advance directives

11. 11 Continuous Quality Improvement Improves and evaluates the delivery of care Comprehensive Diabetes Care Care for Older Adults Adult Assessment Controlling Blood Pressure Cholesterol Management for patients with cardiovascular conditions Medication reconciliation post discharge

12. 12 Continuous Quality ImprovementCont. Consumer Assessment of health plan (CAHPS) are reviewed for highest degree of member satisfaction Patient reports outcomes (Health Outcomes Survey- HOS)

13. 13 Continuous Quality ImprovementCont. UM and QM processes are essential in supporting high quality and effective delivery of care. Grievances and Appeals process Timeliness of referrals Access to care and services Availability of practitioners Clinical Practice guidelines Policies and Procedures Compliance Program Process Improvement

14. 14 Ongoing Activities Improve quality of care through preventive health screenings (HEDIS). Prevention of unnecessary ER utilization, decrease bed days, and increase ambulatory office visits Educational outreach Improve member satisfaction

15. 15 SNP Care Transition Care Transition is defined as the transfer of patient care between health care providers or change in care settings: Educate the patient on discharge plan Follow up for home health or for provider visit

16. 16 National Committee for Quality Assurance-Care Transitions Managing transition Supporting Members through transitions Analyzing Performance Identifying Unplanned transition Analyzing Transitions Reducing Transitions