Model of Care Scoring Guidelines

1. Model of Care Scoring Guidelines SNP Educational Session - January 13, 2014 Brett Kay, AVP, SNP Assessment, NCQA

2. Objectives of SNP MOC Scoring Guidelines • Raise the bar and strengthen the guidelines • Modeled after S&P measures format • 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 Matrix Upload Document—kept requirements intact, but revised formatting

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

6. Public Comment Process • NCQA held a two week public comment period to solicit comments on the draft scoring guidelines • Received input from stakeholders • 222 comments • Health plans, trade associations, provider groups, others • Used feedback to revise guidelines and clarify expectations

7. Public Comment-Major Themes • MOC Audit Issues—requests for clarification/interpretation of requirements; reaction to CMS’ review of MOC during the audit cycle • Requests for better harmonization & coordination of MOC and S&P measures assessments • Redundancy with existing MA requirements

8. Public Comment-Major Themes • Network Model vs. Staff Model—some requirements not feasible/heavy burden for network model SNPs • Plan level vs. member-level data and information • High risk/stratification for ICP/ICT-focus on high need members • Requests for examples, expectations of intent

9. MOC 1: Description of SNP Population • Element A: Overall SNP Population- • Intent: Identify and describe the target population, including health and social factors, and unique characteristics of each SNP type • Response to public comments: • Factor 1: Clarify that emphasis is on process, not care coordination • Factors 2 & 3: Separated social and medical/health factors

10. MOC 1: Description of SNP Population • Element B: Most Vulnerable Beneficiaries • Intent: Describe the most vulnerable beneficiaries and how their medical and social factors affect health outcomes and what services and resources the SNP provides to address these • Response to public comments: • Clarify that focus is on population-level, not individual members

11. MOC 2: Care Coordination • Element A: Staff Structure • Intent: Describe administrative and clinical staff roles and responsibilities • Response to public comments: • Factor 2: Oversight functions related to license and competency verification relates to specific population being served • Factor 4: Contingency plans are developed for plan-level operations • Factors 5&6: Clarify that contracted staff do not include contracted network providers

12. MOC 2: Care Coordination • Element B: Health Risk Assessment Tool • Intent: Describe process for using HRAT to inform development of the ICP; communicate HRAT info to ICT; identify and stratify needs of beneficiaries • Response to public comments: • Factor 3: Establish that all SNP beneficiaries must receive an HRA • Factor 3: SNPs should describe how they address beneficiaries that cannot or will not undergo an HRA

13. MOC 2: Care Coordination • Element C: Individualized Care Plan (ICP) • Intent: Describe essential elements of the ICP, how the SNP develops and updates the ICP • Response to public comments: • Clarify that CMS expects an ICP for all SNP beneficiaries but allows flexibility for SNP to determine level of detail for ICPs—may stratify by risk and place priority on high risk/high need beneficiaries

14. MOC 2: Care Coordination • Element D: Interdisciplinary Care Team (ICT) • Intent: Describe the ICT, including key members, roles and responsibilities and how they contribute to improving beneficiary health status. • Response to public comments: • Clarify that the ICT may meet “virtually” using various forms of communication and technology (face-to-face is not required) • Element E: Care Transition Protocols • Intent: Describe the SNP’s processes to coordinate care transitions and facilitate timely communications across settings and providers • Response to public comments: • Factor 2: Delete requirement about providing staff credentials • Factor 5: Revise to match AHRQ language on self management

15. MOC 3: Provider Network • Element A: Specialized Expertise • Intent: Demonstrate how the network is designed to address the needs of the SNP’s target population • Response to public comments: • Focus is on plan-level information for the provider network • Factor 3: Remove language on credentialing • Element B: Use of clinical practice guidelines (CPGs) and Care Transitions Protocols • Intent: Describe how the SNP ensures that beneficiaries receive appropriate, evidence-based care and services • Response to public comments: • Population level decision making, not individual clinician level • Identify challenges to using CPGs and protocols

16. MOC 3: Provider Network • Element C: Provider Network Training • Intent: Describe how the SNP provides training for its provider network • Response to public comments: • SNPs should show how they make training available to all network providers • Make providers aware of trainings • Offer various training modalities to suit the needs of network providers

17. MOC 4: MOC Quality Measurement & Performance Improvement • Element A: Quality Performance Improvement Plan • Intent: Describe how the SNP conducts quality improvement related to its overall MOC • Response to public comments: • Plan-level information focusing on goals that measure overall plan performance related to all aspects of the MOC

18. MOC 4: MOC Quality Measurement & Performance Improvement • Element B: Measureable Goals • Intent: Identify and define the measureable goals and health outcomes for the target population, and how the SNP determines if goals are being met • Response to public comments: • Plan-level measures and goals for the target population • Focus is on health and clinical goals (e.g., controlling diabetes, mental health screening)

19. MOC 4: MOC Quality Measurement & Performance Improvement • Element C: Measuring Patient Experience • Intent: Describe how the SNP measures beneficiary satisfaction and responds to results • Response to public comments: • Plans may use wide variety of patient experience/satisfaction surveys—CAHPS and HOS are acceptable, as are other alternatives • Provide details of surveys and methodology for data collection

20. MOC 4: MOC Quality Measurement & Performance Improvement • Element D: Ongoing Performance Improvement Evaluation • Intent: Describe how the SNP uses the results from its performance indicators and measures to support its ongoing quality improvement plan • Response to public comments: • Include lessons learned and challenges in obtaining timely data

21. MOC 4: MOC Quality Measurement & Performance Improvement • Element E: Dissemination of SNP Quality Performance • Intent: Describe how the SNP communicates its quality improvement plan and performance to stakeholders • Response to public comments: • Detail who receives the information, how often they receive it, and what communication methods are used

22. QUESTIONS