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Special Needs Plans Model of Care Training 2012. Special Needs Plan Special Needs Plans (SNPs) were created by Congress in the Medicare Modernization.

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Presentation on theme: "Special Needs Plans Model of Care Training 2012. Special Needs Plan Special Needs Plans (SNPs) were created by Congress in the Medicare Modernization."— Presentation transcript:

1 Special Needs Plans Model of Care Training 2012

2 Special Needs Plan Special 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 Plans Two types of SNPs that MHP offers to its members: Medica HealthCare Plans MedicareMax Plus (PSO SNP) for individuals with Dual eligible for Medicare and Medicaid Medica 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 Overview The 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 MHPs SNP Model of Care Explain how MHP Case Management programs work and how contracted providers will work with the Case Management programs Describe 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 Medicare Advantage members with special Needs. It establishes guidelines for: Assessment and case management for members Communication among members, caregivers, and providers Use of an Interdisciplinary Care Team (ICT) of health professionals Participation of Primary Care Physician (PCP) Measurement of individual and program outcome Every SNP member is evaluated annually with a Health Risk Assessment

7 Model of Care Elements The Model of Care is a service delivery mechanism that contains the following 11 elements: 1) Targeted Population 2) Measurable Goals 3) Staff Structure and Roles 4) Interdisciplinary Care Team (ICT) 5) Provider Network 6) Model of Care Training 7) Health Risk Assessment (HRA) 8) Individualized Care Plan 9) Communication 10) Care Management of the Most Vulnerable Population 11) Performance 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 transitions Identifying unplanned transitions, analyzing data to help prevent unplanned transitions and identifying members at risk of unplanned transitions Ensuring safe transitions from initial to final destination Evidenced-based clinical practice guidelines Helping members obtain the services they need regardless of the payer, by coordinating Medicare and Medicaid benefits for members Identifying and assisting those members with changes in their Medicaid eligibility

9 SNP Targeted Population This element describes the members identified for SNP participation based on their needs and qualifications. For MHP these are dual-eligible (D-SNP) members and/or members with chronic disease (D-SNP). These members may have complex medical needs, but they also have increased psychosocial needs to that impact 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 services Medica 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 Goals Improve access to care to medical, mental health, pharmacy and social services Improving access to affordable care Improve access to preventive health services Improve coordination of care through an identified point of contact i.e. PCP or Specialist Assure appropriate utilization of services Provide seamless transition of care Assure cost-effective service delivery

11 SNP Staff Structure Roles Administrative Staff: Process enrollment and verify eligibility for SNPs Process claims and facilitates resolution of grievances and providers complaints Collect, analyze, report and act on performance and health outcome data Conducting quality improvement activities Review and analyze communication data Report to CMS and states Communicate Plan information Management Staff: Monitors MOC implementation and evaluate its effectiveness Assure licensure and competency; statutory and regulatory compliance Monitor contractual services Monitors ITC Assures timely and appropriate delivery of services, seamless transitions and timely follow ups Assures 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 and provide appropriate staff and program oversight: The Medical Director and/or his physician delegate Case and Disease Managers Social worker The plans delegated behavioral health provider The beneficiaries PCP (if applicable) The beneficiary and/or their designated advocate or caregiver (if possible)

13 SNP Provider network Providers with specialized expertise: Primary Care Physicians Multi specialty Providers Behavioral Health Providers Nursing Professionals Network facilities The provider network offers broad practitioner representation from the medical, diagnostic and treatment areas with the specialized expertise to care for Special needs members.

14 Model of Care Training All 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 needs The 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 HRA The reassessment is done annually, or sooner, if it is determined that there may have been a change in the members condition.

16 What is an Individualized Care Plan (ICP)? 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. Individualized care plans are generated by the Case Manager for those members willing to participate, based on the members/care givers answers to assessment questions.

17 Communication Network MHP has many different Communication methodologies. The methods for internal communications are: Face-to-face meetings systems Quarterly Internal Newsletter MHP uses various communication vehicles to disseminate information to its network of providers, such as: Quarterly provider newsletters Fax blasts Mailed announcements and /or educational material Face-to-face meetings

18 Most Vulnerable Beneficiaries MHP defines its most vulnerable population and outlines specific interventions for these members. Most vulnerable beneficiaries are: Frail and/or disabled individuals Beneficiaries developing end–stage renal disease after enrollment Beneficiaries near to end of life Beneficiaries 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 Information A complete version of MHP Model of Care is available at Questions, Contact the Case Management Department at

21 Thank You

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