Annual SNP Model of Care Training 2018

1. Annual SNP Model of Care Training 2018 Robin Tufono RN Coast Healthcare Management LLC.

2. Special Needs Plan 2016 (SNP) • The CMS requires all contracted medical providers to receive basic training about the (SNP) Model of Care. Special Needs plans were created as a part of the Medicare Modernization Act in 2003. Medicare Advantage plans must design special benefit packages for groups with distinct health care needs, providing extra benefits, improving care and decreasing cost for the frail and elderly through improved care coordination. • This course will describe how health plans and the contracted provider networks work together to deliver the SNP Model of Care

3. Whatare Special Needs Plans? • There are three types of SNP’s that serve the following members: • Dually eligible members – Medicare & Medi-Cal– D-SNPS - • Individuals with severe disabling chronic conditions. An initial attestation that member has a specific chronic condition is required from the provider – C-SNPS • Individuals who are institutionalized or eligible for long term nursing home care – I-SNPS The SNP population is comprised of the; frail elderly, disabled chronically ill, and those that are financially compromised.

4. Presentation Overview Presentation will cover: • Goals of the Model of Care • Model of Care 1 – SNP Population • Model of care 2 – Care Coordination • Model of Care 3 – Provider Network • Model of Care 4 – Quality Improvement • Coordination of Medicare and Medi-Cal for D-SNPS • Quality Improvement Programs

5. Learning Objectives • After the training, attendees should be able to: • Describe the basic components of the SNP Model of Care • Explain how Case Management programs work together with providers to coordinate members along the continuum. • Describe the essential role of the contracted providers in delivering the SNP Model of Care • Describe at least 3 benefits of the SNP MOC

6. Features of Special Needs Plans • Medicare SNP’s & Cal Medi-Connect plans are specially designed to have the following features: • Enrollment is limited to Medicare Beneficiaries within the target SNP/Dual population • The benefit plan is custom designed to meet the needs of the designated population i.e. Chronic Care SNP’s – C-SNPS, or D-SNP’s & ISNP’s – Members that are disabled, or financially qualify for Medi-Cal • SNP members normally have an additional election period to change their Medicare coverage – They can enroll in a plan that offers SNP’s all year long!

7. SNP Structure and Process Measures CMS contracts with NCQA to evaluate SNP plans. NCQA has evaluated SNP plans annually for their performance in the following key areas: • Model of Care 1 – SNP Population – General Population and Vulnerable Subpopulations • Model of Care 2 – Care Coordination, Case Management, HRA’s, ICP, ICT, Care Transitions • Model of Care 3 – Provider Network – Specialized Provider Network, Clinical Practice Guidelines, Model of Care Training • Model of Care 4 – Quality Improvement – Measurable Goals, Evaluation of Performance, Communication of Progress Towards Goals

8. Goal of Special Needs & Cal Medi-Connect Plans • Improved Access to affordable and preventive health care services • Improved access to medical, mental health and social services – Long Term Support Services thru Medi-Cal • Improved Coordination of Care through an identified point of contact • Improved Transitions of Care across health care settings and amongst practitioners and providers • Assure Appropriate utilization of services, assure cost effective service delivery and improve health outcomes • Deliver case management programs to assist with patient’s medical & non medical needs, and promote coordinated care along the continuum • Support of the primary plan of care

9. SNP Program Vulnerable Sub-Populations • Frail Elderly – Members 85 years with chronic illness such as; COPD, CHF, Arthritis with hx of falls and or fractures, deteriorating functional status • Disabled members – With declining function, requiring increased assistance with ADL’s • Dementia – Those at risk due to memory issues and or lack of support systems • End of Life – Those diagnosed with end-stage disease i.e.; cancer, lung disease • Complex and multiple chronic conditions – Those with multiple co-morbid conditions, requiring assistance with managing disease and navigating health care systems

10. Required Elements of the MOC • Health Risk Assessment • Case Management • Individualized Care Plans • Interdisciplinary Care Team • Care Transitions • Specialized Network

11. Health Risk Assessment • Annual Health Risk Assessment – An HRA is conducted to identify medical, psychosocial, cognitive, functional and mental health needs and risks • An initial telephonic HRA is done telephonically or by home visit within 90 days of enrollment and annually there after • Three to several attempts are made to contact the member if unable to contact the survey is mailed • The member’s HRA is utilized to identify needs, to assist in developing the individualized care plan • The member is reassessed with any changes in condition and the HRA and care plan are updatedat least annually

12. Provider Role In HRA • Encourage members to complete – Members may ask about the survey encourage their cooperation explaining that it helps you the provider in planning for their care

13. Case Management • All SNP /CMC members are eligible for case management and a single point of contact for care coordination. • Members are notified by phone call and if unable to reach ,by mail. They are given the opportunity to opt out of case management but are contacted during any transition or change in condition and offered CM services • Members with a behavioral health diagnosis are CM by the contracted behavioral health provider

14. Role of the Case Manager • Outreach to the member to perform an initial assessment of medical, psychosocial, cognitive and functional status. Reviews the HRA and incorporates into the assessment and care plan • Develops a patient centric comprehensive individualized care plan with barriers, goals, interventions • Provides Health Coaching Encourages preventive screenings and follow up • Reviews Medications and reconciles across the continuum • Assists the members with navigation and coordination of care across the continuum • Assist members with resources ; community based, State and Federal programs etc. • Promotes appropriate utilization of services - –Ensuring member is getting the right care in the right place at the right time • Educates the members on available benefits and add on benefits • Assesses the need for cultural and linguistic preferences • Expedites the authorization process • Coordinates the Interdisciplinary Team meetings and is communicates amongst the team members • Members with a behavioral health diagnosis are CM by the Plans contracted provider

15. Interdisciplinary Care Team The ICT meets on an as needed basis and or regularly to manage the medical, cognitive, psychosocial and functional needs of the member. Required Team Members • Medical Expert – Medical Director, PCP, • Social Service Expert – Case Manager, Social Worker • Behavioral Health Expert – When indicated

16. Interdisciplinary Care Team • Optional Team Members • Pharmacist • Health Educator • Pastoral Specialist Nutrition Specialist • Restorative Specialist Disease Management Nurse • DMH/IHSS Social Worker • IHSS Caregiver • Other

17. Care Transitions • Members are most vulnerable for poor outcomes when they are transitioning from one level of care to the next i.e.; from acute hospital to home or SNF, rehab setting, from any setting back home with or without home health • SNP member transitions are identified either by prior auth, facility notification, inpatient census etc. • SNP members are contacted as soon as possible after or before the transition, and given single point of contact (transitions team) is introduced to the member and caregivers.

18. Care Transitions • The members care plan is transferred between the discharging facility and the usual practitioner i.e.; medication record, discharge care plan, follow up plans. • The SNP Care transitions coach educates the member on medications, red flags who to call , discharge instructions , and health coaching regarding disease process and changes in condition. • SNP members are assisted with making appointments, required authorizations for follow up, transportation arrangements and any resources required to move member in the right direction.

19. Specialized Provider Network • The plan must maintain a comprehensive network of primary care providers and specialist to meet the needs of the chronically ill, frail and disabled SNP members. • Examples; Palliative Care Team, Homebound Program; SNF Team etc.

20. D-SNPs Coordinating Medicare and Medi-Cal • The goal of coordination of Medicare and Medi-cal benefits for members that are dual eligible • Members are informed of both benefits • Members are informed on eligibility requirements • Members know how to access both benefits • Members are informed of rights to appeals and grievances • Members are assisted to access providers that accept both programs

21. Added Benefits Each Plan has extra benefits to assist in meeting the needs of the designated population. Included below are an example of such benefits: • Coordination of Care Medicare & Medi-Cal Benefits • LTSS – Long Term Support Services – Medi-Cal Benefits • Health and Wellness Programs – Disease Management Programs – SNP’s • Medication Therapy Management Programs • Transportation Benefits Some SNP/Medi Connect plans may have benefits for; Dental, Vision, Gym membership at lower costs

22. Quality Improvement Program Health Plans offering a SNP/Cal Medi-Connect must conduct a Quality Improvement program to monitor health outcomes and implementation of the Model of Care by: • Collecting SNP specific HEDIS measures • Meeting NCQA SNP Structure and Process standards • Conducting a Quality Improvement Project (QIP) annually that focuses on a clinical or service aspect that is relevant to the SNP population • Providing a CCIP – Chronic Care Improvement Program • Collecting data to evaluate annually if SNP/Medi-Connect program goals are met

23. SNP/Cal Medi Hedis Measures & Care of The Older Adult • Disease Management – Osteoporosis women with fracture, blood pressure, RA, medication • Prevention, Screenings, Tests, and Vaccines – Breast CA, Colorectal CA, Osteoporosis, Flu, PNA vaccines • Assessments – Annual Wellness, BMI, Physical Activity, Fall Risk, Bladder Control, Tobacco, Mental Health • Comprehensive Diabetes Care – Blood sugar control, Cholesterol screening, Kidney disease screen, Eye exam, Blood pressure • Care of the older adult – Advance Care planning, Medication review, Functional status assessment, Pain screening

24. Contracted Plans that Offer SNP’s & Cal Medi-Connect The Following Health Plans offer Special Needs Plans and or Cal Medi-Connect plans: • Care 1st Health Plan – Cal Medi Connect • Health Net – DSNP & Cal Medi • LA Care – DSNP & Cal Medi • SCAN – DSNP & Chronic Care SNP • Easy Choice - DSNP • Central Health Plan – DSNP • Brand New Day • Alignment

25. Data Collection and Evaluation • Each domain is evaluated annually to identify areas for improvement and if program goals have been met: • Health Outcomes • Access to Care • Improved Health Status • Implementation of MOC • HRA • COC • Provider Network • Delivery of Extra Services • Integrated Communications

26. Case ManagementContacts • Robin Tufono RN, CCM , Director of CM Programs – 562 259-2548 • Mary Day LVN, Lead Case Manager –All IPA’s. 562 602-1563 Ext. 515

27. Questions ???? After reading this presentation please take the time to write down any questions you may have regarding the training and call any number on the contact list and we will be glad to assist you! THANK YOU!