MOC - Vision

Model of Care 2015
for Dual Special Need Plans
Quality Department
January 2015
Objectives
• Learn about new Model of Care (MOC) changes.
• Learn about our Dual Special Need Plan (D-SNP) products.
• Understand the Four (4) MOC Elements, aimed at improving
healthcare for D-SNP members.
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Definitions
3
Definitions
• Healthcare Effectiveness Data and Information Set (HEDIS®)
– Measures designed to assess members’ healthcare quality
• Health Outcomes Surveys ( HOS®)
• Surveys that gather valid and clinically significant data on patients’
mental and physical wellness
• CareEnhance Care Manager Software (CCMS®)
– Application that provides clinical management information for our
members
• National Committee for Quality Assurance (NCQA)
– Organization contracted by CMS to evaluate D-SNP product
structures, processes and quality
4
Definitions
•
Consumer Assessment of Healthcare Providers and Systems (CAHPS®)
•
•
•
•
Survey that collects, evaluates and reports on the experience (perception) of the members in relation to
services received from insurers and providers
Transition
– Movement of a member from one care setting to another as the member’s health
status changes
Health Care Setting
– The provider or setting from which a member receives health care and healthrelated services. In any setting, a designated practitioner has ongoing responsibility
for a member’s medical care.
First Tier, Downstream or Related Entities (FDRs)
– First Tier Entity - Any party that enters into a written arrangement, acceptable to
CMS, with an MAO ( Medicare Advantage Organization), Part D plan sponsor, or
applicant to provide administrative or healthcare services to a Medicare-eligible
individual under the MA or Part D program (e.g. Catamaran).
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Definitions
– Downstream Entity - Any party that enters into a written arrangement,
acceptable to CMS, with persons or entities involved in MA or Part D
benefits, under an arrangement between an MAO and applicant, or a Part D
plan sponsor or applicant and a first tier entity. These written arrangements
continue down to the level of the final provider of both health and
administrative services. (e.g. contracted pharmacy with Catamaran)
– Related Entity - Any entity related to an MAO or Part D sponsor by
common ownership or control, and performs some of the MAO or Part D
plan sponsor’s management functions under contract or delegation; furnishes
services to Medicare enrollees through an oral or written agreement; or
leases property or sells materials to the MAO or Part D plan sponsor at a
cost of more than $2,500 during a contract period. (See, 42 C.F.R. §423.501).
(e.g. MCS Life Inc./MCS Advantage)
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Definitions
•
Clinical Practical Guidelines (CPG)
– Clinical Practice Guidelines contain systematically developed statements,
including recommendations intended to optimize patient care and assist
physicians and/or other health care practitioners and patients in making
decisions regarding the appropriate health care for specific clinical
circumstances.
•
Centers for Medicare and Medicaid Services (CMS)
– The Centers for Medicare and Medicaid Services (CMS) is a branch of the U.S
Department of Health and Human Services. CMS is the federal agency that
administers Medicare, Medicaid, and the Children's Health Insurance
Program.
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Dual Special Need Plans (D-SNP)
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Dual Special Needs Plan (D-SNP)
Definition
Health plan for people who are eligible to receive benefits from
Medicare Parts A and B, and Medicaid.
Medicare
A+B
Medicaid
Dual Special
Needs Plan
(D-SNP)
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D-SNP Products at MCS
MCS Classicare Has Three (3) D-SNP Products:
Product Name
MCS Contract
Number
MCS Group
Number
1. MCS Classicare Platino Ideal (Renewal 2015)
H5577-002
850614
2. MCS Classicare Platino Máximo (Renewal 2015)
H5577-009
850707
3. MCS Classicare Platino Superior (Renewal 2015)
H5577-010
850708
As of December 2014, the Platino products had a
population of approximately 79,580 members.
D-SNP Background
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D-SNP Background
• Under the Medicare Modernization ACT of 2003
– U.S. Congress created the Special Needs Plan (SNP)
• Under the 2012 Affordable Care Act, which amended Section 1859(f) of
the Social Security Act
– All SNPs must be approved by NCQA (National Committee for Quality
Assurance)
• On May 23rd of 2011
– CMS (Centers for Medicare and Medicaid Services) issued Chapter 16b of the Medicare Managed Care Manual, which provides guidance on
D-SNPs.
• On January 17, 2014
– CMS announced that MOC requirements will be eliminated from
Chapter 16b of the Medicare Managed Care Manual and be included
in Chapter 5 – Quality Improvement Program, application cycle (CY
2015)
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Model of Care
(MOC)
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Model of Care (MOC)
An MOC is considered to be a vital quality improvement tool and
integral component to ensure the unique needs of each enrolled
beneficiary are identified and addressed. MOCs provide the needed
infrastructure to promote quality, care management and care
coordination processes for SNPs.
Quality Department
Responsible for overseeing, monitoring, and evaluating actions
related to MOCs.
MCS has related MOC policies and procedures that you can access
through Compliance 360.
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Get to Know Our Model of Care!
MCS provides programs and
services for our D-SNP
members that consider the
following needs:
- medical
- functional
- cognitive
- psychosocial
- mental health
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Integrated Programs and Services
for Our D-SNP Members
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Integrated Programs and Services for D-SNP
Interdisciplinary Care Team (IDCT):
Member or Caregiver, Member PCP,
MCS Medical Director, MCS Ph.D. ,
RN Care Manager, Social Worker,
Physician Specialist Ad Hoc and/or
other health professional as needed
CHRA
Initial Evaluation
Annual Re-evaluation
Member
Health risk level
and IDCT
assignment
Continuous
communication
process updates
between MCS,
PCP & Member
Care Management
Readmission
Preventive
Program
MCS Care
Management
Program
Update process through
evaluation
Community
Outreach
Program
Health
Education
Mental
Health
Individual Care Plan
for Members and PCPs
Utilization
Management
Pharmacy
Quality Department
evaluates the MOC’s
effectiveness
Integrated D-SNP Programs and Services
After identifying health risk levels through CHRA, the member will
participate in one of the following programs and/or services:
Readmission
Prevention
Program
MCS Care
Management
Program
Mental Health
Community
Outreach
Program
Pharmacy
Health Education
Utilization
Management
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Integrated D-SNP Programs and Services
•
MCS Care Management Program
– Focused on patients with chronic, catastrophic or degenerative illnesses or disabilities
– Coordinates and provides clinical care and services related to medical conditions in
order to monitor the medical treatment plan provided by the primary physician or
specialist
• MCS at Your Side (Special Clinical Programs from Care
Management)
Case Management
(Complex and Acute)
Chronic Condition
Improvement Program
(CCIP)
Readmission
Prevention Program
Community Outreach
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Integrated D-SNP Programs and Services
Acute and Complex Case Management
•
Works with nursing care interventions and
coordinates the necessary services to stabilize
and/or improve health, promoting the
prevention of unnecessary readmissions.
Coordinates care, both for members with
chronic, progressive and terminal conditions,
and members with brief episodes of severe
illness (acute conditions).
•
Complex Case Management Program
Initiatives
–
Chronic Renal Condition (CRD)
–
Terminal Stage Renal Condition (TSRD)
–
Palliative Care
–
Fragility
–
Oncology
–
Pre-transplant
–
Post-transplant
–
Care Transition
–
Coverage Outside the Area
Case Management
(Complex and Acute)
Chronic Condition
Improvement Program
(CCIP)
Readmission Prevention
Program
Community Outreach
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Integrated D-SNP Programs and Services
•
Chronic Condition
Improvement Program
(CCIP)
• Promotes self care and
coordinates interventions for
members with diabetes with
complications:
• Renal
• Periferal/Circulatory
• Ophthalmologic
• Neurologic
Case Management
(Complex and Acute)
Chronic Condition
Improvement Program
(CCIP)
Readmission Prevention
Program
Community Outreach
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Integrated D-SNP Programs and Services
• Readmission Prevention
Program
– Responsible for implementing
strategies to prevent
readmissions for hospitalized
members with a high risk of
readmission
Case Management
(Complex and Acute)
Chronic Condition
Improvement Program
(CCIP)
Readmission Prevention
Program
Community Outreach
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Integrated D-SNP Programs and Services
•
Community Outreach
Program
– Facilitates access to
community services, and
identifies and manages the
non-clinical needs of high risk
members whose health may
be affected
Case Management
(Complex and Acute)
Chronic Condition
Improvement Program
(CCIP)
Readmission Prevention
Program
Community Outreach
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Integrated D-SNP Programs and Services
•
•
Health Education
– Develops and implements
interventions aimed a promoting
health, reducing risk factors
associated with health
complications, and improving
self-care skills for the member’s
condition
Mental Health
– First Health Care (FHC) is the
company contracted by MCS to
coordinate mental and
behavioral health services
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Integrated D-SNP Programs and Services
• Pharmacy
– Designed to optimize therapeutic outcomes, improve
medication use, reduce health risks, and improve compliance
with medication therapy
– Ensures Pharmacy Benefit Management (PBM) compliance with
contractual agreements and procedures to ensure the efficient
and timely delivery of drug services
• Utilization Management
– Responsible for evaluating members’ pre-authorizations ,
discharge planning , and transitional care. Monitor s use and
establishes initiatives to ensure the right service at the right
time
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Crosswalk to New Elements
New Elements
• MOC 1: SNP Population
Old Elements
MOC 1: SNP-Specific Population
MOC 10: Vulnerable Populations
MOC 3: Staff Structure/Care Management Roles
• MOC 2: Care Coordination
Care Transition Protocol NEW!
MOC 4: Interdisciplinary Care Team
MOC 7: Health Risk Assessment
MOC 8: Individual Care Plan
MOC 9: Communication Network
• MOC 3: Provider Network
MOC 5: Provider Network & Use of Clinical
Practice Guidelines
MOC 6: MOC Training
• MOC 4: Quality Measurement
MOC 2: Measurable Goals
MOC 11: Outcome Measurement
4 Model of Care Elements
MOC 1: Description
of SNP Population
MOC 2: Care
Coordination
MOC 3: Provider
Network
MOC 4: MOC
Quality
Measurement and
Performance
Improvement
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MOC 1: Description of the General Population
Element A: Description of the Population
•
In describing our D-SNP population, we took several factors into
consideration. This includes:
– Physical, Mental, Cognitive and Comorbidity Conditions
– Demographic Data (age, sex and origin)
– Social (socioeconomic status, living conditions, language barriers,
cultural barriers, caretaker considerations, and others)
•
Approximately 52% live in urban areas, 90% live in their own home or
apartment (renting or owning), 8% live with family members, and 1.2%
live in nursing homes.
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MOC 1: Description of the General Population
Element A: Population Description
•
According to a CAHPS (Consumer Assessment of Health Providers and
Systems) survey, 80.5% claimed to have never finished high school.
•
The most prevalent diagnoses among MCS members in groups contracted
in 2013 were:
*Hypertension, diabetes mellitus and episodic mood disorders
*Based on a 2014 analysis and 2013 claims related to services from
January to June 2013.
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MOC 1: Description of the General Population
Element B: Most Vulnerable Sub-population
•
•
•
The population identified as the most vulnerable are the
following members:
– Fragile
– Disabled
– Terminal Stage
– Developing renal failure at the terminal stage
– Multiple complex chronic conditions
Of those members who reported having a caregiver, 43.3% depend on this
person for their daily living activities, for example, in the preparation of
food or for transportation.
In addition, 80% reported that they live with a family member who
supports them with their healthcare and treatment recommendations.
MCS has established mechanisms for identifying the most
vulnerable D-SNP population members.
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MOC 2: Care Coordination
Element A: Personal Structure
MCS has an organizational structure that allows us to coordinate, integrate and
monitor clinical and administrative aspects that affect MOCs.
•
•
•
Administrative Personnel
– Eligibility (enrollment verification)
– Claims
– Management Personnel
Clinical Personnel (requires credentialization verification)
– Care Management (RN)
– Pharmacy
– Discharge Planning (RN)
– Consultants (MDs, Dentists, etc.), Health Educators, among others
MCS also provides MOC training, both initially and annually to employees and
contracted personnel.
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MOC 2: Care Coordination
Element B: Health Risk Assessment (HRA)
The primary source for identifying the individual needs of
D-SNP members is the:
Complete Health Risk Assessment (CHRA)
1.
2.
3.
4.
The D-SNP member should visit his or her primary physician and have an
initial evaluation within 90 days after becoming a member.
This evaluation will identify the health level according to the member’s
physical, functional cognitive, psychosocial and mental health needs.
According to the identified health risk level, an Interdisciplinary Care Team
will be assigned.
Before 12 months after the initial evaluation, the member should visit his
or her primary physician for a re-evaluation.
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MOC 2: Care Coordination
Element C: Individual Care Plan (ICP)
An individual care plan is designed based on the needs identified in
the CHRA.
•
•
•
•
The individual care plan is an initial and follow-up tool, whereby care
management documents evaluate the person’s current health status, with
actions taken aimed at meeting the member’s needs.
It is evaluated regularly and when the member’s health requires it.
It includes goals, problems and interventions that have been provided to the
member.
It provides a structure for organizing an interdisciplinary team, with the
information shared among the team members.
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MOC 2: Care Coordination
Element D: Interdisciplinary Team (ICT)
Based on the automated results of the CHRA stratification, members are
assigned an interdisciplinary team of professionals responsible for developing
and implementing an individualized care plan.
Members of the Interdisciplinary Team:
1. Member’s PCP
2. Member
3. MCS Medical Director
4. MCS Pharmacist
5. Nurse – MCS Care Manager
6. Social Worker – MCS Community Outreach Representative
7. Medical Specialist (if necessary)
8. Mental Health Professionals
9. Other Health Professionals, if necessary
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MOC 2: Care Coordination
Element D: Interdisciplinary Team (ICT)
•
MCS has established two interdisciplinary teams: .
Standard and Complex
Standard Interdisciplinary Team:
– Meets at least once a year to review the individualized standard care plans
aimed at those members who, according to their CHRA, have an estimated
low/light and medium/moderate health risk.
– This group is in charge of reviewing the recommendations aligned with the
updated clinical medical practice guidelines.
– When a member is reclassified at a high risk/severe risk level in his or her
CHRA re-assessment, the person is referred to special MCS At Your Side
clinical programs and a complex interdisciplinary team.
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MOC 2: Care Coordination
Element D: Interdisciplinary Team (ICT)
•
Complex Interdisciplinary Team:
– Serves the most vulnerable members and may include the following additional
members as necessary:
• Medical Specialist Treating the Member,
• Preventive Health Educator/Health Promotion,
• Pastoral Specialist,
• Restorative Health Specialist (physical, occupational, speech or
recreational therapist),
• Nutrition Specialist,
• Home Healthcare Professional, Caretaker, or Family Member
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MOC 2: Care Coordination
Element D: Interdisciplinary Team (ICT)
•
Complex Interdisciplinary Team Cont. :
– Supports MCS At Your Side programs, and usually meets once a month to
discuss cases.
• The care manager contacts the member and invites the person to
participate in the program and they agree on an individualized care plan.
• The plan has specific interventions to address problems and reach
established clinical goals while in contact with the PCP and the rest of the
team attending to the member.
• The individual care plan is shared with the member and/or the authorized
representative and the person’s PCP.
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MOC 2: Care Coordination
Element D: Interdisciplinary Team (ICT)
•
Complex Interdisciplinary Team Cont.:
– All documentation management and case discussions occur within MCS’s
electronic file system, which allows members of the complex interdisciplinary
team to monitor the member while he or she is receiving services during the
various care stages.
– The care manager is responsible for reporting the member’s preferences to
the interdisciplinary team.
– Also responsible for communicating the interdisciplinary team’s
recommendations to the member.
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MOC 2: Care Coordination
Element E: Care Transition Protocols NEW
Planned Transition:
Scheduled movement of a
member from one care setting
to another
Unplanned Transitions:
Unexpected movement of a
member from one care setting
to another
• Example: Elective surgery or a
decision to enter a SNF
• Emergency room visit leading to
a hospital admission
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MOC 2: Care Coordination
Element E: Care Transition
•
MCS manages and coordinates care transitions, ensuring the continuity of
the member’s services. The planned care and unplanned care processes
are managed through the following units:
• Intra-hospital Services
• Discharge Plan
• Care Management
•
MCS educates members during the care transition process in the following
ways:
• Care Transition Letter to the Member and PCP
• 24/7 Medilínea
• Educational Material for the Condition’s Self-care (Cuídate Magazine,
Preventive Reminders (Diabetes, Cardiovascular, etc.)
• Telephone
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MOC 3: Provider Network
Element A: Specialists
•
•
•
MCS provides access to a specialized network that helps meet the member’s
needs. This includes, but is not limited to: Internists, Endocrinologists,
Cardiologists, and Mental Health Specialists, among others.
We also have providers such as: Primary Physicians, Dentists, Home Health
Services, Hospitals and Rehabilitation Centers, Skilled Nurses, and more, who
meet qualifying criteria.
Examples:
– Provider and Medical Facility Credentialization and Re-credentialization
Process:
• Credentialization – Initial Contracting Process
• Re-credentialization – Every 36 Months
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MOC 3: Provider Network
Element B: Use of Clinical Practice Guidelines and Care
Transition Protocol
MCS Adopts Clinical Practice Guidelines (CPG) for Acute and
Chronic Conditions, and for Preventive Services
Clinical guidelines are documents developed systematically to help
physicians and patients make decisions regarding the best medical care for
a specific condition or circumstance.
Examples: Cancer, Hypertension, Diabetes, Asthma, and others
• Our provider network uses the proper nationally recognized Clinical
Practice Guidelines.
• For cases with complex health needs, the Clinical Practice Guidelines may
be modified to meet the unique needs of the most vulnerable members.
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MOC 3: Provider Network
Element C : Provider Network Training
• MCS provides initial and annual training to providers and first
level, second level and related entities (FDRs).
• Training is also given to non-participating providers that
routinely offer services to a member.
• Some of the topics included in the educational interventions
are the 4 Elements, requirements requested by CMS, and
topics of a related impact.
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MOC 4: Quality Measurement and Performance
Improvement
Element A: MOC Quality Performance Plan
For its outcome evaluation, MCS uses data obtained from
various sources, comparing it with identified quality measures
and aligning it with the MOC goals.
Data Source
Measure
Indicators
• CCMS
• CHRA
• Claims (MHS)
•HEDIS
•CAHPS
•Utilization Report
•CMS Regulatory Reports
•Operational Reports
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MOC 4: Quality Improvement Measures and
Evaluation
Element B: Measurable Goals and Health Outcomes
MCS defines various kinds of goals when evaluating the Model of Care.
Examples:
– HEDIS- Diabetes Care Evaluation
• Reports related to diabetes care test monitoring
– CAHPS
• Is it easy to make an appointment with your specialist?
– Regulatory Reports
• Reports on the use of coronary angioplasty procedures
– Operational Reports
• Percent of members evaluated for identifying depression
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MOC 4: Quality Improvement Measures and
Evaluation
Element C: Member’s Care Experience (Member Satisfaction)
– Population Satisfaction Survey
• MCS carries out various processes to evaluate and monitor
members’ care experiences, including but not limited to CAHPS,
HOS and specific internal surveys.
– Satisfaction Survey for the Most Vulnerable Population
• Focused on members who voluntarily participate in Managed Care
programs.
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MOC 4: Quality Improvement Measures and
Evaluation
Element D: Evaluation of Continuous MOC Improvement
To continue with the quality improvement process, MCS monitors
and analyzes quality indicators to identify improvement
opportunities.
Some of the quality indicator sources include:
–
–
–
–
–
–
–
HEDIS®
Member Satisfaction Surveys
CAHPS®
HOS®
Provider Satisfaction Surveys
Member Complaints and Appeals
Provider Complaints, among others
When result goals are not met, improvement opportunities are identified and
actions are implemented to improve performance.
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MOC 4: Quality Improvement Measures and
Evaluation
Element E: Communicating the MOC Quality Evaluation
MCS uses various methods to report on quality improvement
related to the Model of Care, such as:
– Quality Improvement Program Evaluations
– Letters
– Provider Communications
Information regarding MOC results is also reported to:
–
–
–
–
The Board of Directors
Discharge Management Personnel
Employees
Providers, and others
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Thank you for your commitment to a better
quality of life for our D-SNP members!
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For any questions, call the
Quality Department:
Wanda J. Mojica RN, BSN, MBA
MOC Manager
Ext. 4890
[email protected]
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References
•
•
•
•
•
MCS SNPs 2015 Model of Care Description
Medicare Managed Care Manual – Quality Improvement Program Chapter
5 Section 20.2 Additional Quality Improvement Program Requirements for
Special Needs Plans (SNPs) 20.2.1 Model of Care (MOC) General
MCS P&P: QUAL-OP-001 - Dual Special Needs Plans Model of Care
Oversight
MCS P&P: QUAL-OP-002 - D-SNP Model of Care Goals Analysis
SNP Model of Care (MOC) Summaries
at CMS website:
http://www.cms.gov/Medicare/Health-Plans/SpecialNeedsPlans/SNP-ModelOf-Care-Summaries.html
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