SNP Training – Topic 4: Structure & Process Measures 4 through 7

1. March 17, 24, 31 and April 2, 7,15, 2009 SNP Training – Topic 4: Structure & Process Measures 4 through 7

2. Objective of S&P Measures Training • Describe the SNP assessment project NCQA is executing on behalf of CMS • Explain the intent of the S&P Measures • Determine what type of documentation to provide • Demonstrate how NCQA will survey the 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 • 1st year—rapid turnaround, adapted existing NCQA measures and processes from voluntary Accreditation programs • 2nd year—focus on SNP-specific measures • 3rd year—Refine measures; identify new SNP-specific measures, where appropriate

5. Three-Year Strategy

6. Who Reports • HEDIS measures • All SNP plan benefit packages with 30+ members as of February 2008 Comprehensive Report (CMS website) • S&P measures • All SNP plan benefit packages • Plans with no enrollment exempt from certain elements

7. What to Report • S&P measures • Cohort I—All SNPs operational as of January 1, 2007 and renewed in 2009. • S&P measures 4-7 (SNP 2:C & 3:B) • Cohort II—All SNPs operational as of January 1, 2008 and renewed in 2009 • All S&P measures (SNP 1-6) • Do not report SNP 7 (SNP 2:C & 3:B)

8. Project Time Line – Phase II • March 4- Release final S&P measures • March 30 - Release ISS Data Collection Tool • S & P Measures • April - Release IDSS Data Collection Tool • HEDIS Measures • June 30 - HEDIS submissions and S&P measures submissions due to NCQA • October 30 - NCQA delivers SNP Assessment Report to CMS

9. SNP Structure and Process Measures Brett Kay, Director, SNP AssessmentCasandra Monroe, Assistant Director, SNP AssessmentAisha Pittman, Senior Health Care Analyst, Performance Measurement

10. S&P measures: What’s New for 2009 • SNP 1-3: Added 2 new elements (SNP 7 in ISS) • SNP 2C (SNP 7A): Improving member satisfaction • Focus on implementing interventions to address member satisfaction issues • SNP 3B (SNP 7B): Clinical measurement activities • Focus on collecting, analyzing relevant clinical data • Identifying opportunities for improvement based on data analysis • Existing elements: added more examples and clarified explanations

11. S&P Measure Development Process • Identify highest ranking priorities in coordination with GMAP (2/08) • Conduct plan interviews (5/08) • Draft measures with assistance from SNP TEP (6/08) • Conduct Pilot Test with plans (7/08) • Release measures for public comment (10/08) • Finalize (1/09)

12. Objectives of New S&P Measures: SNP 4 Care Transitions • Overall focus on SNP-specific functions • All members: Monitoring members’ movement between care settings • Ensuring transfer of information such as medication and care plans • Initially more emphasis on monitoring transitions to and from acute care settings • In subsequent years, measures will assess monitoring all aspects of all care transitions

13. Objectives of New S&P Measures: SNP 5 Institutional SNP Relationship with Facility • Institutionalized members: Monitoring members care • Plans should monitor members health status quarterly • Plans should ensure that changes in members health status are responded to quickly • In subsequent years, measures will assess quality of health status information collected

14. Objectives of New S&P Measures: SNP 6 Coordination of Medicare &Medicaid • Dual-eligible members: Members should feel as if they are seamlessly enrolled in one plan • Plans should identify members’ eligible Medicaid and Medicare benefits and services and assist them in obtaining them • Plans should work with state Medicaid agencies to contract to provide Medicaid benefits • This element assesses plans progression towards meeting MIPPA requirements • In subsequent years, the measure will assess plans ability to integrate Medicare and Medicaid

15. Components of the S&P Measures • Standard statement: a statement about acceptable performance or results • Intent statement: A sentence that describes the importance of the S&P measure • Element: The component of the measure that is scored and provides details about performance expectations. NCQA evaluates each element within the measure to determine the degree to which the SNP has met the requirements within the S&P measure.

16. Components of an S&P Measure • Factor: An item within an element that is scored (e.g., an element may require an organization to demonstrate that a specific document includes 4 items. Each item is a factor). • Scoring: The level of performance the organization must demonstrate to receive a specific percentage on each element (100%, 80%, 50%, 20%, 0%) • Data source: Types of documentation or evidence that the organization uses to demonstrate performance on an element. NCQA defines 4 types of data sources:

17. Data Source Types • Documented Processes: Policies and procedures, process flow charts, protocols and other mechanisms that describe an actual process used by the organization • Reports: Aggregated sources of evidence of action or compliance with an element, including management reports; key indicator reports; summary reports of analysis; system output giving information; minutes; and other documentation of actions that the organization has taken • Materials: Prepared materials or content that the organization provides to its members and practitioners, including written communication, Web sites, scripts, brochures, review and clinical guidelines • Records or Files: Actual records or files, such as denial, appeal or credentialing flies that show direct evidence of action or compliance with an element---NCQA does not require file review for phase two.

18. Components of an S&P Measure • Scope of Review: The extent of the organization’s services evaluated during an NCQA survey. • Look-back period: The period of time for which NCQA evaluates an organization’s documentation to assess performance against an element • Explanation: Guidance for demonstrating performance against the element • Example: Descriptive information illustrating performance against an element’s requirements. Examples are for guidance and are not intended to be all-inclusive

19. SNP 4: Care Transitions

20. SNP 4: Element AManaging Transitions • Managing & coordinating planned/unplanned transitions from one care setting to another • Factors 1& 2 focus on transitions to and from a hospital • Factors 3-6 focus on transitions to and from other care settings • Factor 7 requires an analysis of plans’ management of transitions • Focus is providing information and communication from one setting to another: • Providers/practitioners • Caregivers • patients

21. SNP 4: Element AManaging Transitions • Documentation • Documented processes AND Reports or materials • Must specify a timeframe for completion of required transition activities in factors 3-6 • Transitions to/from hospital must address activities in factors 1-6 • Transitions to/from other care settings must address activities in factors 3-6, at a minimum

22. SNP 4: Element A FAQs • Does NCQA want to see an analysis for Factor 7, or just a plan to conduct the analysis? • SNPs may present a plan or process that details how it will conduct an analysis. The actual analysis is not required this year. • Can SNPs provide job descriptions of staff responsible for managing transitions? • Yes. SNPs may provide job descriptions as an example of materials detailing transition coordination activities.

23. SNP 4: Element A Examples • Policies & procedures for supporting members’ moves b/w care settings, including items to be completed by each setting • Policies & procedures for communicating with members or responsible parties • Formats for reports used to identify planned transitions, changes in member health status and hospitalizations ordered by providers • Information prepared for members experiencing transitions.

24. SNP 4: Element B Identifying Unplanned Transitions • Review the following information for network facilities: • hospital admissions w/in one business day of admission • LTC facility admissions w/in one business day of admission • Organization or member’s usual practitioner must manage the transition

25. SNP 4: Element B • Documentation: organization must provide both: • Documented processes, AND • Reports • Examples to show plan implements its policies

26. SNP 4: Element B FAQs • Can the organization use reports from its staff who regularly see members in hospitals and LTC facilities? • Yes. The reports may come from organization staff or from the facilities directly. They may also come from UM or other standard reporting processes. • Should a SNP provide actual patient data in the admissions reports? • No. Plans should NOT send any personal health information (PHI). All patient identifiable data should be removed. • Report formats or shells of daily admissions reports are sufficient for this element.

27. SNP 4: Element B Examples Documentation may include: • Procedures for reporting by contracted facilities • Must include the organization’s time frame for receiving reports • Procedures for organization staff to report on members’ transitions • Format or shell of daily admissions reports from hospitals • Format or shell of organization staff notification of member transitions, based on organization staff visits to facilities or contact with facility staff

28. SNP 4: Element CReducing Transitions Focus is on minimizing unplanned transitions and keeping patients in least restrictive setting • Analyze individual member data to identify those at risk • Patient-specific data • Coordinate services for at-risk members • High-risk members • Educate members/caregivers-prevent unplanned transitions • Analyze member admissions—hospitals and ED visits • Annual analysis to identify areas for improvement • Population focus (aggregate data)

29. SNP 4: Element CReducing Transitions Documentation: SNPs must provide: • Documented processes AND • Reports • Formats or shells for factor 1 • Actual analysis for factor 4

30. SNP 4: Element C FAQs • Can an organization use the data it collects from its case management program (SNP 1: Complex Case management, Elements A, B, & D) to meet the requirements of factor 1? • Yes, provided the organization analyzes information on all members with the same frequency as it does for case management, to predict possible transitions for individual members • Can an organization assign responsibility for factors 1, 2, 3 to other providers? • Yes. However, the organization is ultimately responsible for meeting the requirements.

31. SNP 4: Element CExamples • Documented Processes • Procedures for case managers to contact at-risk members to assess needs and arrange services • Procedures for ordering needed services or working with providers to order them • Reports • Format or shell of reports identifying high-risk patients using claims or other data • Format or shell showing predictive modeling to assign members a risk score • Reports on overall rates of admissions and ED visits, analysis of root causes and opportunities for improvement

32. SNP 5: Institutional SNP Relationship with Facility

33. SNP 5: Institutional SNP Relationship with Facility • Institutional SNPs only • Focus is on communications with facilities to monitor member needs and services provided • Dual Eligible and Chronic Care SNPs are exempt • Score all elements in this measure “NA”

34. SNP 5: Element A • Organization monitors information on member health status at least quarterly • Scoring is 100% or 0% (all or nothing element) • Communication should include information that may indicate a change in health status or no change • Status reports may include: • Functional status assessments • Medication regimen • Self-reported health status • Reports on falls, socialization and depression

35. SNP 5: Element A • Documentation: SNPs must provide: • Documented processes AND • Reports or materials

36. SNP 5: Element A FAQs • If an organization collects the required data as part of its case management functions, will that meet the requirements for this element? • Yes, provided the data is collected at least quarterly • Can SNPs use data derived from MDS or other systematic data collection? • Yes. MDS or other reports specified by the SNP from the institutional facility that report on member health status are acceptable

37. SNP 5: Element A Examples • Documented Processes • Procedures for network facilities to provide ongoing updates on member health • Contracts or agreements with facilities covering their monitoring and reporting responsibilities • Reports? • Format or shells of reports of staff visits to facilities to collect member health status info • Materials • Facility briefing materials

38. SNP 5: Element B Monitoring Changes in Members’ Health Status • Requires network institutions to notify SNP or treating practitioner with 24-48 hours of change in members’ health status • Organization sets parameters for: • Triggering events/changes to report • Who should be contacted (plan or practitioner) • Timeframe for reporting

39. SNP 5: Element B Monitoring Changes in Members’ Health Status Documentation Requires • Documented processes; AND • Procedures for network facility to provide notification • Contracts or agreements with facilities covering their reporting responsibilities • Reports or materials • Format or shell of reports of member health change reports from staff visits • Format or shell of member health change reports from facilities

40. SNP 5: Element B FAQs • Can a SNP require different timeframes for notification for different issues such as falls, weight loss, etc? • Yes. The SNP may set its own notification parameters, however, they cannot exceed 48 hours to receive full credit for this element • When does the timeframe for notification start, at the time of the health status change or the identification of that change? • The timeframe begins once someone (facility or SNP staff) identifies that an eligible health status change or triggering event has occurred. For example, a member gets a fever at 3:00am, but it is not observed or recorded until 6:00am. The timeframe for notification to the SNP/practitioner starts at 6:00am.

41. 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

42. SNP 5: Element C Documentation must include: • Documented Processes; AND • Policies and procedures for how the organization and facilities respond to triggering events and changes in health status • Contracts or agreements with facilities covering their reporting responsibilities • Materials • Job descriptions of staff who visit members in facilities • Facility briefing materials

43. SNP 5 Element C Examples Methods of providing care: • Organizations 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

44. SNP 6: Coordination of Medicare and Medicaid Coverage

45. SNP 6: Element A Administrative Coordination for Dual-Eligible Benefit The organization coordinates Medicare & Medicaid benefits/services by: • Providing members (current & prospective) with information on both programs • Providing information about maintaining Medicaid eligibility • Identifying changes in member Medicaid eligibility • Giving members access to staff knowledgeable about both programs • Coordinating adjudication of Medicare/Medicaid claims • 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

46. SNP 6: Element A FAQs • If we are an Institutional SNP, do we have to complete this element? • No. SNP 6: Element A is applicable only to Dual-eligible SNPs. Institutional and Chronic care SNPs should select “NA” in the survey tool for this element and document that they are either an I-SNP or C-SNP • We operate in a state that does not allow us to integrate our marketing materials for Medicare & Medicaid. How can we demonstrate compliance with this element? • Plans that operate in states where integrated marketing or other member information is not permitted may provide separate benefit materials to members/prospective members, e.g., one brochure on the Medicare benefits and one for the Medicaid benefits.

47. SNP 6: Element A Examples • SNPs must provide documented processes and may provide any one of the other two data sources to meet element requirements: • Documented processes: • Job descriptions for staff who help members with coordination of both sets of benefits • Procedures used to determine changes in Medicaid eligibility • Materials: • Sample marketing materials; brochures, benefit summaries • Instructions on where to reapply for Medicaid • Reports: • Format or shell of reports on Medicaid eligibility used by organization

48. SNP 6: Element BRelationship with State Medicaid Agency The organization has a documented relationship with the state Medicaid agency to promote coordinated care • For Dual-eligible SNPs only that: • Have a contract/agreement with state agency • Are working toward a contract/ agreement

49. SNP 6: Element B Documentation • SNPs may provide documentation from any one of the data sources • Documented Processes: • Contracts or agreements with the state Medicaid agency covering administration or benefits • Procedures for administering Medicaid benefits, where the procedures reflect an ongoing process • Reports: • Written notification of a scheduled meeting with state to discuss contracting w/in past 12 months or notification acknowledging receipt of, or action on, organization’s proposal for contracting to administer Medicaid benefits w/in past 12 months • Materials: • Instructional materials from state agency on how to administer Medicaid benefits

50. SNP 6: Element B FAQs • Our SNP operates in a state that refuses to contract with Medicare health plans to coordinate or administer Medicaid benefits. How can we comply? • In situations where the state cannot or will not enter into an agreement with the SNP, the SNP may take an “NA” for this element. SNPs must document this with a letter or legislation/regulations from the state that indicate such refusal/inability to act