2 Special Needs PlanSpecial Needs Plans (SNPs) were created by Congress in the Medicare Modernization Act (MMA) of 2003 as a new type of Medicare managed care plan focused on certain vulnerable groups of Medicare beneficiaries: the institutionalized, dual-eligibles and beneficiaries with severe or disabling chronic conditions. These beneficiaries are typically older, with multiple comorbid conditions, and thus are more challenging and costly to treat.
3 MHP Special Needs Plan’s Two types of SNP’s that MHP offers to its members:Medica HealthCare Plans MedicareMax Plus (PSO SNP) for individuals with Dual eligible for Medicare and MedicaidMedica HealthCare Plans MedicareMax Chronic Care (PSO SNP) for individuals with severe or disabling chronic conditions such as diabetes and/or cardiovascular disorders, to include cardiac arrhythmias, coronary artery disease, peripheral vascular disease, and chronic venous thromboembolic disorder
4 SNP Course OverviewThe Centers for Medicare and Medicaid (CMS) require all contracted medical providers to receive basic training about the Special Needs Plans (SNP) Model of Care.The SNP Model of Care (MOC) is the plan for delivering coordinated care and case management to special needs members.This course will describe how MHP and its contracted providers can work together to successfully deliver the SNP MOC.
5 SNP Learning Objectives After the training, attendees will be able to :Describe the basic components of MHP’s SNP Model of CareExplain how MHP Case Management programs work and how contracted providers will work with the Case Management programsDescribe essential role of contracted providers in delivering the SNP MOC.
6 What is the SNP MOC?Is the plan for delivering case management and services for MedicareAdvantage members with special Needs. It establishes guidelines for:Assessment and case management for membersCommunication among members, caregivers, and providersUse of an Interdisciplinary Care Team (ICT) of health professionalsParticipation of Primary Care Physician (PCP)Measurement of individual and program outcomeEvery SNP member is evaluated annually with a Health Risk Assessment
7 Model of Care ElementsThe Model of Care is a service delivery mechanism that contains thefollowing 11 elements:Targeted PopulationMeasurable GoalsStaff Structure and RolesInterdisciplinary Care Team (ICT)Provider NetworkModel of Care TrainingHealth Risk Assessment (HRA)Individualized Care PlanCommunicationCare Management of the Most Vulnerable PopulationPerformance and Health Outcome Management
8 What is the scope of our Model of Care ? Looking for improvement opportunities:Managing the process of care transitions, identifying problems that could cause transitions, and where possible preventing unplanned transitionsIdentifying unplanned transitions, analyzing data to help prevent unplanned transitions and identifying members at risk of unplanned transitionsEnsuring safe transitions from initial to final destinationEvidenced-based clinical practice guidelinesHelping members obtain the services they need regardless of the payer, by coordinating Medicare and Medicaid benefits for membersIdentifying and assisting those members with changes in their Medicaid eligibility
9 SNP Targeted Population This element describes the members identified for SNP participation based ontheir needs and qualifications. For MHP these are dual-eligible (D-SNP) membersand/or members with chronic disease (D-SNP). These members may havecomplex medical needs, but they also have increased psychosocial needs to thatimpact compliance with care plans and health outcomes.Medica HealthCare Plans MedicareMax Plus (D-SNP) for individuals with Dual eligible for Medicare and Medicaid benefits and servicesMedica HealthCare Plans MedicareMax Chronic Care (C-SNP) for individuals with severe or disabling chronic conditions such as diabetes and/or cardiovascular disorders, to include cardiac arrhythmias, coronary artery disease, peripheral vascular disease, and chronic venous thromboembolic disorder
10 SNP Model of care GoalsImprove access to care to medical, mental health, pharmacy and social servicesImproving access to affordable careImprove access to preventive health servicesImprove coordination of care through an identified point of contacti.e. PCP or SpecialistAssure appropriate utilization of servicesProvide seamless transition of careAssure cost-effective service delivery
11 SNP Staff Structure Roles Administrative Staff:Process enrollment and verify eligibility for SNP’sProcess claims and facilitates resolution of grievances and providers complaintsCollect, analyze, report and act on performance and health outcome dataConducting quality improvement activitiesReview and analyze communication dataReport to CMS and statesCommunicate Plan informationManagement Staff:Monitors MOC implementation and evaluate its effectivenessAssure licensure and competency; statutory and regulatory complianceMonitor contractual servicesMonitors ITCAssures timely and appropriate delivery of services, seamless transitions and timely follow upsAssures providers use clinical practices guidelines
12 Interdisciplinary Care Team (ICT) The ICT is composed of several key clinical disciplines, including:The MHP SNPs have an appropriate medical team with clearly defined roles.The team provides the infrastructure necessary to coordinate the plan of care andprovide appropriate staff and program oversight:The Medical Director and/or his physician delegateCase and Disease ManagersSocial workerThe plan’s delegated behavioral health providerThe beneficiaries PCP (if applicable)The beneficiary and/or their designated advocate or caregiver (if possible)
13 SNP Provider networkThe provider network offers broad practitioner representation from the medical,diagnostic and treatment areas with the specialized expertise to care for Specialneeds members.Providers with specialized expertise:Primary Care PhysiciansMulti specialty ProvidersBehavioral Health ProvidersNursing ProfessionalsNetwork facilities
14 Model of Care TrainingAll internal personnel and contracted providers are trained on the Model of Care. All employees that have responsibilities for services provided to SNP enrollees receive training as part of their new employee orientation.They are provided with an electronic copy of a Power Point presentation to review initially and they are also given a SNP-MOC Training Manual that they can refer to after the initial training is completed. All internal employees also receive MOC update training annually.
15 What is an HRA?HRA is a Health Risk Assessment . This tool has questions that addresses several areas pertinent for the evaluation of medical, functional, cognitive and psychological problems in order to have a complete picture of the patients needsThe interview is done via telephone and in the event that the patient does not respond and after three attempts then the form is sent via mail with a postage paid envelope. The initial Risk Assessment is being done within the first 90 days after enrollment and within 1 year of last HRAThe reassessment is done annually, or sooner, if it is determined that there may have been a change in the member’s condition.
16 What is an Individualized Care Plan (ICP)? Individualized care plans are generated by the Case Manager for those members willing to participate, based on the members/care giver’s answers to assessment questions.The member/care giver, case manager and providers are involved with short and long term goal settings, interventions and the identification of barriers for each of the problem areas.
17 Communication Network MHP has many differentCommunication methodologies.The methods for internalcommunications are:Face-to-face meetingssystemsQuarterly Internal NewsletterMHP uses variouscommunication vehicles todisseminate information to itsnetwork of providers, such as:Quarterly provider newslettersFax blastsMailed announcements and /oreducational materialFace-to-face meetings
18 Most Vulnerable Beneficiaries MHP defines its most vulnerable population and outlines specificinterventions for these members. Most vulnerable beneficiaries are:Frail and/or disabled individualsBeneficiaries developing end–stage renal disease after enrollmentBeneficiaries near to end of lifeBeneficiaries having multiple or complex chronic conditions
19 Performance & Health Outcome Measurement Goals Monitor coordinator of care through the PCP: This goal focuses on the compliance of the member visiting the PCP at least quarterly, to assure the implementation and follow up on the care plan.Assure seamless transitions and timely follow-ups: This goal focuses on the timeliness and appropriateness of post-discharge coordination of care. The goal is to follow-up all members within 7 days of hospital discharge.Ensure access to preventative care services: Monitors HEDIS prevention and screening measure results. This goal focuses on the access to preventive care services. These services are accessed thru the coordination of care based on HRA and case management assessment.Special Needs Structure & Process Measures Evaluation: Monitor s annual results and recommendations and corrective action plans if applicable.Evaluate measurable health outcomes and implementation of interventions: Monitor s measure outcomes submitted to QA Committee, HEDIS, CAPHS and HOS results as described in General Preventative Outcomes Measures .
20 For More InformationA complete version of MHP Model of Care is available atQuestions, Contact the Case Management Department at