1. Assessing Quality Improvement in Special Needs Plans Marsha Davenport, MD, MPH CAPT USPHS Chief Medical Officer Medicare Drug and Health Plan Contract Administration Group (MCAG) October 28, 2011

2. Purpose and Overview Describe the current Quality Improvement (QI) Program activities for the Special Needs Plans (SNPs) Discuss assessment versus performance measurement Discuss status of structure, process and outcomes measures 2

3. Purpose and Overview (cont’d) Provide and update on the chronic care improvement programs (CCIPs) and the quality improvement projects (QIPs) Provide an update on the future directions for the QI Program Summary 3

4. Quality Improvement (QI) Program Applies to all MAOs, including SNPs Seven components of the QI Program Serves to integrate and coordinate all of the assessment tools and reporting requirements 4

5. QI Program (cont’d) Chronic care improvement program (CCIP) Meet the requirements of 42CFR §422.152(c) Addresses populations identified by CMS based on review of current quality performance Quality improvement projects (QIPs) Meet the requirements of 42CFR §422.152(d) Expected to have a favorable effect on health outcomes and enrollee satisfaction Address areas identified by CMS 5

6. QI Program (cont’d) Develop and maintain a health information system Encourage providers to participate in CMS and Health &Human Services (HHS) QI initiatives Contract with an approved Medicare CAHPS vendor to conduct the Medicare CAHPS satisfaction survey 6

7. QI Program (cont’d) Include a program review process for the formal evaluation of the QI Program that addresses at least the following areas on an annual basis: Impact Effectiveness Take remedial action to correct problems identified using ongoing quality improvement 7

8. SNP QI Program Model of care (MOC) Eleven elements 1. Description of the SNP-specific target population 2. Measurable goals 3. Staff structure and care management goals 8

9. SNP QI Program Model of Care Eleven elements Description of the SNP-specific target populations Measureable goals State structure and care management goals Interdisciplinary team (ICT) Provider network having specialized expertise and use of clinical practice guidelines and protocols 9

10. SNP QI Program (cont’d) Eleven elements (cont’d) MOC training for personnel and provider network Health risk assessment tool (HRAT) Individualized care plan Communication network Care management for the most vulnerable subpopulations Performance and health outcome measurement 10

11. Defining Quality Quality MeasuresBeneficiariesEvaluationAudits CCIPs and QIPs Core ValuesSafety Public Reporting Standards of Care Models of Care Sharing Best Practices

12. ASSESSMENT Clinical Protocols CCIP MOC Tools for internal assessment: QIPs Measures Plan ratings Structure and process measures Outcomes measures 12

13. Quality Improvement Tool Kit 13 CCIPs MOC Plan ratings S&P measures QI Program Plan QIPs ActPlan DoStudy

14. Structure and Process Measures SNP1: Complex case management SNP2: Improving member satisfaction SNP3: Clinical quality improvements SNP4: Care transitions SNP5: Institutional SNP relationship with facility SNP6: Coordination of Medicare and Medicaid coverage 14

15. Development of Outcomes Measures Purpose of current contract with RAND is to develop specific outcomes measures for the MA program and SNPs Working on the Pilot Study Completing recruitment of plans Will conduct over the next few months Developing the protocol and sample design for the larger validation study 15

16. CCIPs and QIPs Provided feedback to MAOs on the 2010 submissions These submissions helped identify the need for specific training and revision of reporting tools 16

17. Future Directions Implementing CMS-wide MA Quality Strategy Revising the CCIP and QIP tools Conducting training on these new tools Improving resources and technical assistance (TA) 17

18. Summary Quality is a focus for the MA Program, including SNPs Achieve quality health care through a strong QI program and strategy Continue to identify and develop better clinical outcomes measures to demonstrate the impact the MA program has on improving health and health outcomes for our beneficiaries. 18

19. Contact Marsha Davenport, MD, MPH CAPT, USPHS Chief Medical Officer Medicare Drug and Health Plan Contract Administration Group (MCAG) Marsha.davenport@cms.hhs.gov 410-786-0230 19