1 / 46

SNP Approval Model of Care Training Elements 1-2 January 21, 2014 2:00 – 4:00PM EST

Brett Kay, NCQA Sus an Radke, CMS Sandra Jones, NCQA. SNP Approval Model of Care Training Elements 1-2 January 21, 2014 2:00 – 4:00PM EST. Objectives of SNP MOC Scoring Guidelines. Revise structure of the MOC to help plans better understand and meet the requirements

jedidiah-braylon
Download Presentation

SNP Approval Model of Care Training Elements 1-2 January 21, 2014 2:00 – 4:00PM EST

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Brett Kay, NCQA Susan Radke, CMS Sandra Jones, NCQA SNP Approval Model of Care Training Elements 1-2January 21, 2014 2:00 – 4:00PM EST

  2. Objectives of SNP MOC Scoring Guidelines • Revise structure of the MOC to help plans better understand and meet the requirements • Model after S&P measures format • Approach 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 Upload document—kept requirements intact, but revised formatting • Received input from stakeholders: Public Comment process • 222 comments • Health plans, trade associations, provider groups, others

  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 Guidelines

  6. Crosswalk to New Elements Old Elements New Elements • MOC 1: SNP Population • MOC 2: Care Coordination Care Transitions Protocol NEW! • MOC 3: Provider Network • MOC 4: Quality Measurement

  7. Project Time Line • February 25 – MA/SNP & Medicare-Medicaid Plans (MMP) Applications submitted to CMS via HPMS • March 11 –MMP application results to CMS • MA/SNP reviews continue • March 17 – CMS issues Deficiency Notices to MMPs -- Begin “Cure Process” - Plans have 7-10 calendar days to submit additional information • March 18 MMP Cure 1 TA call for Plans scoring <70%

  8. Project Time Line • March 24 Cure 1 MMP Apps due to CMS • April 28 – CMS issues Notice of Intent to Deny • April 30 – MA/SNPs & MMP TA call for Plans scoring <70% • May 8- MA/SNP & MMP Cure Apps due • May 28 – CMS issues MA/SNP Denial Notices & MMP Status Notices • June 2- SNP bids due to CMS

  9. MOC 1: Description of SNP Population Sandra Jones

  10. MOC 1: Description of SNP Population Intent: Identify and describe the target population, including health and social factors, and unique characteristics of each SNP type • Focus is on a description that: • Provides a foundation upon which the remaining measures build a complete continuum of care (e.g. end-of-life & special considerations) for current and potential members the plan intends to serve. • Includes specially tailored services for members considered “most vulnerable” (e.g. multiple hospital admissions or excessive spending on medications above set limits)

  11. MOC 1 Element A: Overall SNP Population Factor 1 • MOC Description: Emphasis is on process* and relevant resources used, not care coordination: • Member identification • Verification of eligibility • Tracking *Process includes information on systems or data collection methodology used to identify and track eligible beneficiaries

  12. MOC 1 Element A: Overall SNP Population Factor 2 Separated social and medical/health factors; the focus is on social, cognitive and environmental factors*. • MOC description must also include • Social & environmental factors; living conditions • Cultural or linguistic challenges • Barriers to health care delivery • Caregiver concerns *Potential factors that may interfere with provision of health care or services, caregiver considerations or other concerns.

  13. MOC 1 Element A: Overall SNP Population Factor 3 Focus is on medical/health/cognitive factors* • MOC description must also include • Current health status of members • Associated behavioral health issues • Co-morbidities *Disease characteristics that could impact present status

  14. MOC 1 Element A: Overall SNP Population Factor 4 • Characteristics of population per SNP type • Includes limitations & barriers that affect overall health • C- SNP – chronic conditions, incidence & prevalence • D-SNP – Full/partial; including limitations & barriers • I-SNP –Facility type; specialty providers & services; limitations & barriers

  15. MOC 1B: MostVulnerable Beneficiaries Intent: Describe the most vulnerable beneficiaries and how their medical/social factors affect health outcomes and what services/resources the SNP provides to address these • Focus: • Important to note that the focus is on population-level, not individual members • Simply put, what makes them “different”?

  16. MOC 1 Element B:Most Vulnerable Beneficiaries Factor 1 • Plan definition of “most vulnerable” and includes: • Robust & comprehensive description of members • Methodology used for identification (e.g. specify data collected from various resources, multiple admits/readmits, high pharmacy utilization, high risk stratification, specific diagnosis & subsequent treatment required) • Medical, psychosocial, cognitive or functional challenges • Any specially tailored services geared towards this population

  17. MOC 1 Element B:Most Vulnerable Beneficiaries MOC includes a description of the most vulnerable members specifically: Factor 2 • Explain how certain characteristics (e.g. average age, gender, ethnicity, language barriers, etc.) affect health outcomes of the “most vulnerable”: • Demographic characteristics (e.g. average age, gender, ethnicity, language barriers, health literacy, socioeconomic status Factor 3 • Draw a correlation between demographic characteristics and clinical requirements: • Specify how the characteristics adversely affect health status & outcomes and the need for unique clinical intervention

  18. MOC 1 Element B:Most Vulnerable Beneficiaries Factor 4 • Establish relationships with community partners • Describe the process for partnering with community providers to deliver needed services: • Type of specialized resources and services • How the Plan facilitates member/caregiver access • Guarantee provision of continuity of eligible services

  19. QUESTIONS

  20. MOC 2: Care Coordination Brett Kay

  21. MOC 2: Element A: SNP Staff Structure Intent: Describe admin/clinical staff roles and responsibilities • Focus: • How care coordination (e.g. health care needs, preferences and sharing information across health care staff and facilities) occurs • All elements must address the SNP’s care coordination activities in detail

  22. MOC 2: Element A: SNP Staff Structure Factor 1: Describe the administrative staff roles, responsibilities, and oversight functions. • Identify & describe employed or contracted staff that perform administrative functions: • Enrollment and eligibility verification • Claims processing • Administrative oversight

  23. MOC 2: Element A: SNP Staff Structure Factor 2: Describe the clinical staff roles, responsibilities and oversight functions • Identify & describe employed or contracted staff that perform clinical functions including: • Directing beneficiary care & education • Care coordination • Pharmacy consultation • Behavioral health counseling • Clinical oversight (e.g., describe how license/competency verification relates to specific population being served)

  24. MOC 2: Element A: SNP Staff Structure Factor 3: Coordination of responsibilities and job title • Describe how identified staff responsibilities coordinate with job title e.g. impact of staff changes: • Title or position • Levels of accountability

  25. MOC 2: Element A: SNP Staff Structure Factor 4: Contingency plan • Identify & describe contingency plans to ensure continuity of staff functions. Factor 5: Initial & annual MOC training • Describe the process for conducting initial & annual MOC training • Training content & strategies • Employed & contracted staff* *Contracted staff do not include physicians or other providers

  26. MOC 2: Element A: SNP Staff Structure Factor 6: Maintaining training records • Describe how the plans documents & maintains training records: • Process for documenting completion of required training; and • How/where the Plan maintains training records

  27. MOC 2: Element A: SNP Staff Structure Factor 7: Corrective actions: • Describe the actions taken if staff do not complete required MOC training • Explain challenges to completing training for employed and contracted staff • Actions taken for missed or deficient training

  28. MOC 2: Element B: Health Risk Assessment Tool Intent: Describe how the HRAT collects and uses data to assess medical, functional, cognitive, psychosocial and mental health needs of members. • Focus: • How the HRAT is used to develop the ICP • Dissemination of information to ICT • Process for conducting the initial and annual assessments • Methodology used to review, analyze and stratify HRA results

  29. MOC 2: Element B: Health Risk Assessment Tool Factor 1: Describe the use and dissemination of HRAT information: • Describe the data collected: • Medical • Functional • Cognitive • Psychosocial; and • mental health needs of members • Process for developing and updating the ICP in a timely basis

  30. MOC 2: Element B: Health Risk Assessment Tool Factor 2: Disseminating HRAT information • Describe the process for sharing HRAT information with the ICT • ICT use of HRAT information • Integration of results into the ICP Factor 3: Initial HRA & annual reassessment • Describe the process including: • Timeframe for conducting (e.g. initial & annual) • Methodology (mailed, in-person, phone interview) • Contacting members not responding to mailings or calls

  31. MOC 2: Element B: Health Risk Assessment Tool Factor 4: Plan & rationale • Describe the process used to review, analyze and stratify HRAT results • Detail stratification process • Communication of stratification results: • ICT • Provider network (e.g. specialty providers, allied or behavioral health practitioners) • Members/caregivers; other SNP personnel as applicable • Explain how the SNP uses results to improve care coordination

  32. MOC 2: Element C: Individualized Care Plan (ICP) Intent: Describe how the ICP is developed and communicated • Focus • Describing the essential elements of the ICP • Detail the process for development/modification • Identify staff responsible • How updates to the ICP are: • Documented • Maintained; and • Communicated.

  33. MOC 2: Element C: Individualized Care Plan (ICP) Factor 1: ICP essential components • Description includes: • Member’s self management goals & objectives • Personal health care preferences • Services specifically tailored to beneficiary’s needs

  34. MOC 2: Element C: Individualized Care Plan (ICP) Description includes: • Factor 2: ICP development process & staff responsible • Process for ICP development • Details staff responsible e.g. role & functions, professional requirements and credentials • Factor 3 • Personnel responsible for development of ICP, including involvement of member/caregiver

  35. MOC 2: Element C: Individualized Care Plan (ICP) • Factor 4 • Process for determining the frequency for review & modification when changes occur • Factor 5 • Communication of updates and modifications to the ICP

  36. MOC 2: Element D: Interdisciplinary Care Team (ICT) Intent: Describe the key components of the ICT • Focus: • Key members of ICT • Roles/responsibilities • How the ICT contributes to improving beneficiary health status • Communications within the ICT

  37. MOC 2: Element D: Interdisciplinary Care Team (ICT) Factor 1: ICT membership • Description includes: • How the SNP determines key members of ICT e.g. specialized expertise requirements • Process for facilitating participation of beneficiary/caregiver • Use of member HRAT results & ICP to identify ICT membership • Explain how ICT uses health care outcomes to evaluate established processes

  38. MOC 2: Element D: Interdisciplinary Care Team (ICT) Factors 2 & 3: ICT Roles & responsibilities • Description includes: • Use of clinical managers, case managers & others to provide interdisciplinary care • How the SNP includes member/caregiver in the process • Provision of needed resources • How the SNP facilitates member/caregiver access to ICT members

  39. MOC 2: Element D: Interdisciplinary Care Team (ICT) Factor 4: Communication plan • Description includes: • Evidence of an established communication plan • Process for maintaining effective and ongoing communication • Verification of communication e.g. ICT meeting minutes, ICP documentation • Communication with members identified with challenges e.g. hearing impairments, language barriers or cognitive deficiencies

  40. MOC 2: Element E: Care Transition Protocols Intent: Describe the SNP’s processes to coordinate care transitions and facilitate timely communications across settings and providers. • Focus: • Factor 1: The process for coordinating transitions • Factor 2: Personnel responsible for coordination efforts • Factor 3: Description of coordination between settings during a care transition • Factor 4: How beneficiaries have access to personal health information to facilitate communication with providers • Factor 5: Education provided to members/caregivers to manage conditions and avoid transitions • Factor 6: Process used to notify members/caregivers of staff assigned to support member through transitions

  41. MOC 2: Element E: Care Transition Protocols Factor 1: Process for coordinating transitions • The description must specify: • Process & rationale used to connect members with appropriate providers • Factor 2: Personnel responsible for coordination efforts • Identify & describe staff responsible for: • Coordinating care transition process • Ensuring follow-up services e.g. scheduling appointments, needed resources

  42. MOC 2: Element E: Care Transition Protocols Factor 3: Applicable transitions • Description of the steps staff managing transitions take before, during & after transitions Factor 4: Access to health information • Process for facilitating member/caregiver access to health information necessary to communicate with providers in other healthcare settings or outside the network.

  43. MOC 2: Element E: Care Transition Protocols Factor 5: Self-management activities • Education provided to members/caregivers to manage conditions and avoid transitions • Signs & symptoms of worsening condition • How to respond to changes Factor 6: Notification of point of contact • Process used to notify members/caregivers of staff assigned to support member through transitions

  44. Training & Education • Sessions focus on MOC Requirements & Technical Assistance -- MOC Elements 1 & 2 (1 training) • January 21* 2:00-4:00pm ET -- MOC Elements 3 & 4 (1 training) • January 23* 2:00-4:00pm ET -- Technical Assistance Calls 2:00 – 3:30 pm ET • February 11 • March 18 for MMP scored <70% • April 30 MA/SNPs & MMPs scored <70% * Recordings and slides available on NCQA SNP Approval website within one week of call

  45. CMS Contacts For technical inquires related to the MOC program plan requirements, appeals/denials or other issues related to the SNP/MMP approval proposal in the regulations, please contact CMS at: CMS SNP mailbox SNP_mail@cms.hhs.gov Subject line: SNP MOC Inquiry CMS MMP mailbox mmcocapsmodel@cms.hhs.gov Subject line: MMP MOC Inquiry NCQA SNP Approval Website for training recordings and slides: www.ncqa.org/snpapproval

  46. QUESTIONS

More Related