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Sharing Best Practices for Special Needs Plans GuildNet Laura Brannigan, BS, BSN, MA Senior Vice President Quality Improvement January 13, 2013 1.

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Presentation on theme: "Sharing Best Practices for Special Needs Plans GuildNet Laura Brannigan, BS, BSN, MA Senior Vice President Quality Improvement January 13, 2013 1."— Presentation transcript:

1 Sharing Best Practices for Special Needs Plans GuildNet Laura Brannigan, BS, BSN, MA Senior Vice President Quality Improvement January 13, 2013 1

2 About GuildNet 2 The Guild was established in 1914 Mission is to assist those with vision loss to live independently and with dignity Not for Profit and non-sectarian Merger with Lighthouse Guild International Presently called Jewish Guild HealthCare

3 Jewish Guild Health Care: Vision + Services Low Vision Clinic Medical Services- DTC Diabetes Care Psychiatric Clinic Mental Health Day Treatment Developmental Disabilities Day Treatment Crisis Counseling SightCare Bressler Prize GuildScholar Award GuildCare – Adult Day Health Care Workplace Technology GuildNet – Managed Long Term Care GuildNet Gold – Medicare Advantage SNP GuildNet Health Advantage GuildNet Gold Plus Independent Living Skills Guild School Children’s Vision Health Initiative 3

4 Our History Established in 1997, the MLTC enrolled its first members in 2000 Expansions: Nassau and Suffolk Counties in 2007 Added GN Gold, a MA SNP/MAP in 2008 and GN Health Advantage in 2012 Expanded MLTC in Westchester and Staten Island in 2013 GuildNet is one of the largest programs of its kind in NY state Over 15,050 members, 584 GNG Approximately 400 employees in 4 sites 4

5 GuildNet’s Mission To provide comprehensive Care Management services to blind, visually impaired and multi-disabled individuals. To promote GuildNet members functioning with dignity in their community for as long as possible. To add value to our members and the health care system by: ▫ Coordinating the most effective health care services for our members while achieving optimal outcomes. ▫ Promoting health knowledge, wellness and safety 5

6 Impact of Vision on Health Care  Vision impairment contributes significantly to excess hospital length of stay  adds 2.4 days  patients four times more likely to have rehabilitative care prescribed on discharge  Visually impaired patients experience more problems after discharge  Decline in vision status is associated with lower emotional, physical and social functioning  Visually impaired patients are less satisfied with their healthcare

7 GuildNet Gold Fully Capitated Program Medicare Advantage Special Needs Plan /Medicaid Advantage Plus Fully integrated dually eligible population (FIDE) Must be determined skilled nursing facility eligible by score > 5 on Universal Assessment System( UAS-NY) NYC(except SI) and Long Island counties All health care services are covered Goal of the plan is to improve health outcomes by improving access to and coordination of care

8 Structure Zero cost share plans Provide integrated Medicare and Medicaid services Primary point of contact for members Role of additional GuildNet Departments

9 Provider Network For Medicare and dually covered services  Extensive network available through Emblem’s Provider network  Credentialed by Emblem  Point of Service (members may go out of network) For Medicaid services  GuildNet Long Term Care network  Credentialed by GuildNet Providers use evidence-based practice guidelines

10 Care Management Model 10 Participant/Participant Designee PCP Home Health Aide Pharmacy Community Services HealthCare Professionals (OT, PT, MH, CHHA) Hospital/LTC/ Facilities IDT

11 Care Coordination Strategies 11 PRE-ENROLLMENT In home visit occurs by RN prior to enrollment PSCP developed WITHIN 2 WEEKS Care Manager calls Particpant to discuss PSCP 6 MONTHS FROM ENROLLMENT Mental Health/Social Worker contacts member to assess In home Reassessment occurs using HRA tool PSCP updated using HRA score and input from Participant ONGOING COMMUNICATION BETWEEN IDT AND PARTICIPANT VIA TELEPHONE USING THE PARTICPANT’S PREFERRED LANGUAGE

12 Process Flow Overview 12 ACT 1) Evaluate current benefits and available community resources 2) Deploy referrals, services and resources to implement care plan PLAN 1) IDT Develops a comprehensive, individualized care plan based on the initial assessment and collaboration with IDT team and member/caregiver's prioritized goals 2) Identify anticipated barriers to successful implementation of plan/goals ASSESS Member screened using a Health Risk Assessment tool, interview call from Case Manager and/or In home Assessment

13 Process Flow Overview Cont’d 13 REVISE OR CONTINUE Revise Plan as needed, adjust resources and referrals and communicate to IDT team and member/caregiver FOLLOW UP 1)Follow up with member/caregiver and provider within the specified timeframe 2) Assess progress to goals and additional barriers COMMUNICATE 1) Mail/Fax Care Plan to member's PCP 2) Mail Care Plan to Member/Caregiver

14 Transitions: Best Practices Challenges:  Obtaining D/C reports from hospitals  Notification of a transition from members What works for us ▫ Audit of transition records  Includes potential causes of unplanned transitions such as readmission in less than 30 days  Monitors adherence to protocol for medication reconciliation and PCP visit within 2 weeks of D/C  Provide feedback to Care Management team Transitions of Care Work Group 14

15 Key Ideas Short Term Workgroup Formation ▫ Multi-departmental teams focused on implementing rapid cycle QI projects ▫ Focus on implementing interventions and disband  Example: PCP Collaboration and Transitions of Care Align required Quality Projects (CCIP, QIP, State) with MOC Goals ▫ All activity targets improvement in important areas Select two or three core ideas to drive all improvement ▫ GuildNet focused on:  Increasing collaboration between the Plan and PCP  Increasing the number of annual PCP wellness visits  Streamlining Care Management Process for Transitions of Care 15

16 Putting It all Together Special Needs Plans need to focus on a few core objectives to drive improvement ▫ Barriers may be significant for this dual eligible population Results ▫ Model of Care Evaluations ▫ Model of Care Metrics ▫ HEDIS Improvement ▫ Member Satisfaction GuildNet’s Future ▫ FIDA – Fully Integrated Dual Advantage Plan ▫ Quality Improvement Focus 16

17 Thank You! Comments or Questions? Laura Brannigan, BS, BSN, MA Senior Vice President Quality Assurance/Performance Improvement. GuildNet Jewish Guild Healthcare 212-769-7852 Email: Visit our Website for more information about GuildNet: 17

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