SNP 4 through 6 Training

1. July 18, 24 and 30, 2013 SNP 4 through 6 Training

2. Objectives of SNP Training • Review NCQA’s year-to-year approach to the project and reporting requirements for SNPs • Describe the changes in the S&P measures for the 2013 SNP Assessment • Explain how NCQA assesses plans’ performance with individual elements in the S&P Measures

3. Objectives of SNP Assessment Program • Develop a robust and comprehensive assessment strategy • Evaluate the quality of care SNPs provide • Evaluate how SNPs address the special needs of their beneficiaries • Provide data to CMS to allow plan-plan and year-year comparisons

4. SNP Assessment: How did we get here? • Existing contract with CMS to develop measures focusing on vulnerable elderly • Revised contract to address SNP assessment 2008 - rapid turnaround, adapted existing NCQA measures and processes from Accreditation programs 2009 - focused on SNP-specific measures 2010 - refined existing measures 2011 - clarified requirements in SNP 1 thru 6 2012 - refined measures and documentation requirements; focus on implementing interventions

5. Who Reports • HEDIS measures • All SNP plan benefit packages with 30 or more members as of February 2012 Comprehensive Report (CMS website) • S&P measures • All SNP plan benefit packages • Plans with zero enrollment as of April 2013 Comprehensive Report are exempt for certain elements

6. SNP Reporting • Returning SNPs— all SNPs that were operational as of January 1, 2012 AND renewed for 2013 AND have previously submitted. • SNP 1 A-G, SNP 2A-C, SNP 3-6 • New SNPs — all SNPs operational as of January 1, 2012 AND renewed for 2013 AND are reporting for the first time. • SNP 1 A-D, SNP 2A-C, SNP 4-6

7. Project Time Line – 2013-2014 • June 2013 through September 2013- Training for SNPs • June & July 2013 - Release S&P Measures in hardcopy and ISS Data Collection Tool • October 15, 2013 - S&P Measure submissions due to NCQA • October 15, 2013 to April 30, 2014 – S&P reviews conducted by NCQA and surveyors • June 2014 - NCQA delivers SNP Assessment Report to CMS

8. Structure and Process Measures

9. SNP 4: Care Transitions

10. SNP 4: Care Transitions • Focuses on coordination of information related to transitions of care from one setting to another (e.g., hospital to home) • Identify “at-risk” members and take actions to prevent or reduce unplanned transitions • Coordinate services • Educate members

11. What’s Changed? • No major content, documentation or scoring changes • Element E—Added a new factor that requires plans to take actions or interventions related to the opportunities identified in factor 2. • Element E—clarified that plans may use their existing CMS QIP related to reducing hospital admissions to satisfy factor 3 requirements

12. SNP 4 Element A: Managing Transitions • Managing & coordinating planned/unplanned transitions from one care setting to another • Factor 1 focuses on planned transitions to and from a hospital • Requires SNP to show it is aware that a transition is about to take place—before it happens and provide support throughout the transition process, not just after discharge • A preauthorization policy included in documentation must show how it triggers clinical action. Cannot solely pertain to a coverage or payment decision.

13. SNP 4 Element A • Factor 2 specifies requirements for planned and unplanned transitions to and from a hospital • Sending setting must share care plan with receiving setting within 1 business day of transition notification • Care plan consists of patient info that facilitates communication, collaboration and continuity of care across settings • Org determines what info care plan includes • Must specify practitioner to receive care plan for planned transitions to hospital—must show evidence SNP shared care plan with practitioner w/in specified timeframe

14. SNP 4 Element A • Factor 3: Notifying member’s usual practitioner of transition • planned and unplanned transitions to and from all care settings • must specify a timeframe for completion of transition activities, e.g., • 24-48 hours prior to member movement to receiving setting • within 1 business day of member’s discharge • at least 2 calendar days before the scheduled procedure

15. SNP 4 Element B Supporting Members Through Transitions • Communications with members/caregivers within specified timeframes regarding: • the transition process and what to expect • changes in health status and their care plan • who will support them through the process • Factors 1 thru 3 pertain to planned andunplanned transitions to and from all care settings

16. SNP 4 Element B • A SNP’s documented process for factors 1 thru 3 must specify a timeframe for completion of required transition activities • The following do not qualify as timeframes • during the encounter …. • upon identification of transition needs …. • regular contact and review …. • on an ongoing basis …. • during discharge ….

17. SNP 4 Element C • SNPs must include all activities from Elements A & B in the analysis: • assess the frequency a SNP performs the following functions: • Identify planned transitions • Share care plan across settings w/in 1 bus. day • Notify usual practitioner • Communicate w/ member about transition process • Communicate w/member about care plan • Communicate w/member about point of contact

18. SNP 4 Element C • The intent of the aggregate analysis for this element is for plans to assess how well they are managing transition activities. • Factors 1 and 3 need to show: • data collected; • a quantitative and qualitative analysis; and • the opportunities for improvement • Factors 2 and 4 must describe: • the universe of members in the sample • sampling methodology • how the SNP drew at least 3 months of data

19. SNP 4 Element C What is an Analysis? • An evaluation of aggregate performance that includes: • quantitative data – number of transitions in the denominator for a factor and the number of transitions where the SNP performed the activity specified by the factor within any pertinent timeframes • qualitative data – notations on results, trends, anomalies, assessment of causes/reasons for findings • identification of opportunities and recommendations for further action

20. SNP 4 Element D Identifying Unplanned Transitions • A SNP must show that it: • has a documented process and reviews reports of hospital admissions within 1 business day of the admission • Must show at least 3 admissions • reviews reports of long-term care facility admissions within 1 business day of the admission • Must show at least 3 admissions

21. SNP 4 Element E • Focus of element is on minimizing unplanned transitions and keeping patients in least restrictive setting • Factor 1 requires an analysis of patient-specific data to identify those at risk • E.g., claims, UM or provider reports, predictive modeling

22. SNP 4 Element E • A SNP’s documentation for factor 1 needs to show: • data collected—must monitor all members • members targeted • areas where it acts to minimize the risk of unplanned transitions and keep members in the least restrictive setting

23. SNP 4 Element E Factor 2 requires SNPs to analyze data and identify areas where avoidable, unplanned transitions can be reduced • Analyze member admissions to all hospitals and ED visits • Population focus (aggregate data) • Actual analysis to identify areas for improvement

24. SNP 4 Element E • SNP’s documentation for factor 2 must show: • data collected • quantitative and qualitative analysis • opportunities for improvement. • SNP must include in-network and out of network facilities and EDs in this analysis for factor 2. If it only includes in-network facilities, it does not receive full credit for this factor (cannot score >50%).

25. SNP 4 Element E • New clarification!SNP must provide evidence of 1 analysis performed after 10/15/12 • Data collected must be dated after 10/15/12 • Analyses must be SNP-specific; organizations that perform an aggregate analysis of multiple benefit plans must break out the data for each individual plan

26. SNP 4: Element E • New for 2013: Factor 3—implementing interventions • The SNP must implement at least one intervention from the opportunities identified in factor 2 during the look-back period. • Do not have to show improvement or effectiveness of the intervention • SNPs can use their existing CMS QIP related to reducing hospital readmissions

27. SNP 4 Element F Reducing Transitions Factors 1 and 2 require a SNP’s documentation to show that it: • Coordinates services for at-risk members • Educates these members or their caregivers on how to prevent unplanned transitions Actions must relate to findings from monthly analyses in SNP 4:E, factor 1

28. SNP 4 Element F • Factor 1—Care Coordination may be done through Case Mgmt or other programs; SNP must maintain special procedures if all members are not in CM • Factor 2—Educational opportunities must be related to specific, targeted populations, not just general health education

30. SNP 5: Institutional SNP Relationship with Facility

31. SNP 5 Element A Monitoring Members’ Health Status • Institutional SNPs only • Focus is on communications with facilities to monitor member needs and services provided • Facilities include contracted nursing facilities and assisted living facilities • The SNP must show that it monitors information on members’ health status at least monthly • Communication should include information that may indicate a change in health status or no change

32. SNP 5 Element A • Scoring • 100% or full credit • Institutional SNPs who monitor at least monthly • 50% or partial credit • Institutional SNPs who monitor at least quarterly • 0% or no credit • Institutional SNPs who monitor less often than quarterly

33. SNP 5 Element A • Monitoring methods a SNP can use: • data derived from MDS or other reports on member health status it requires from the institutional facility • reports from its staff who visit members in facilities • data on members’ health status it collects through care management if collected on a monthly basis • Status reports may include: • Functional status assessments • Medication regimen • Self-reported health status • Reports on falls, socialization and depression

34. SNP 5 Element A • Documentation • a SNP must provide a documented process and one additional data source or it does not receive full credit for this element • Element is NA for: • An Institutional SNP that shows it does not have contracts with nursing facilities or assisted living facilities • all members reside in the community • Dual Eligible and Chronic Care SNPs are exempt • Score all elements in this measure “NA”

35. Polling Question • True or False • An Institutional SNP that only has contracts with and members residing in assisted living facilities is exempt from reporting SNP 5 Element A

36. SNP 5 Element B Monitoring Changes in Members’ Health Status • Organization monitors and responds to triggering events and changes by: • Setting parameters for the types of changes and triggering events contracted facilities must report within 48 hours, 3 calendar days and 4 to 7 calendar days • Identifying who will act on that information and should be contacted • Identifying how the member’s care will be coordinated with appropriate clinicians or the clinical care plan • Identifying one monitoring or data collection method it uses to assess changes in all members’ health status

37. Factor 1 Details • An organization must submit evidence that shows it has identified specific conditions or early warning signs and symptoms that facilities must report within a minimum of: • 48 hours • 3 calendar days • 4-7 days • The SNP must submit a documented processand reports or materials showing how and when facility staff must report a list of triggers such as: • changes in vital signs • changes in the member’s behavior • changes in their functional status • complaints of pain

38. SNP 5 Element B • Explanation of scoring • 100% or full credit • The organization meets all 4 factors • 50% or partial credit • The organization meets 3 factors including factors 1 through 3 (critical factors) • 0% or no credit • The organization meets 0-2 factors or does not meet factors 1, 2 or 3

39. SNP 5 Element B • The SNP must demonstrate it monitors members through one of the following methods: • Reports from facilities to the organization such as Minimum Data Set (MDS) • Reports from organization staff who visit the members • Oversight of facility monitoring and reporting changes to treating practitioners rather than to the organization • A combination of the processes above

40. SNP 5 Element C Maintaining Members’ Health Status • Organizations use the information from SNP 5 Elements A&B to identify at-risk members and work with facilities/practitioners to arrange for necessary care and adjust care plans as needed to prevent declines in member health status • Scoring is 100% or 0% (all or nothing element)

41. SNP 5 Element C Methods of providing care: • SNPs may have differing models of relationships with facilities to address these monitoring functions • Facility oversight: relies on facilities to modify/carry out care plans • Staff practitioners: SNP staff practitioners visit facilities and order care plan modifications • Other models of care: SNPs may use a combination of above models or different one

42. SNP 5 Element C Documentation • A SNP must submit: • Documented Processes; AND • Policies describing increases in frequency of visits to member by the organization’s nurse managers to assess, revise the care plan and monitor his or her condition after a health status decline and resulting inpatient stay • Reports • Screenshots from the organization’s care management system documenting monitoring visits, assessments and care plan changes the nurse managers discussed with the member’s treating practitioner and notes confirming the practitioner’s agreement

43. Questions?

44. SNP 6: Coordination of Medicare and Medicaid Coverage

45. What’s Changed? No major changes in 2013!!!

46. SNP 6 Element A Not Applicable for C-SNPs & I-SNPs Coordination of Benefits for Dual-Eligible Members Dual-eligible SNPs coordinate Medicare & Medicaid benefits/services for their members by: • Giving members access to staff knowledgeable about both programs • Providing clear explanations of rights to pursue grievances/appeals under both programs • Providing clear explanations of benefits and any communications they receive re: claims, cost sharing

47. SNP 6 Element A • Documentation - SNPs must provide reports and may include documented processes or materials to supplement them • Reports: • Evidence of Coverage (EOC) documentation • Materials: • Scripts or guidelines for staff who help members with eligibility, benefits and claims for both Medicare and Medicaid (Factors 1 & 2) • Job descriptions for staff who help members with eligibility, benefits and claims for both Medicare and Medicaid

48. SNP 6 Element A • For all factors — SNP must provide information to members for Medicare AND Medicaid. The SNP cannot receive credit for any factor where itprovides the required information for only Medicare without a report demonstrating resources for information on Medicaid.

49. SNP 6 Element A • Documentation must show: • SNP’s materials cover the details of members’ specific benefit plans • It gives members information on staff who can answer questions regarding both programs in lieu of written documents • SNP staff can answer questions about Medicare benefits and the state’s payment cost-sharing as well as Medicaid eligibility and cost-sharing for services where the member is liable.

50. SNP 6 Element B Not Applicable for C-SNPs & I-SNPs Administrative Coordination of Dual-Eligible Benefit Packages A dual-eligible SNP coordinates Medicare and Medicaid benefits for its members by: • Identifying changes in members’ Medicaid eligibility • Coordinating adjudication of Medicare/Medicaid claims for which it is contractually responsible