QI 7: Complex Case Management (HPA Only)

SNP 1 through 3 Training

July 9, 11 and 16, 2013

Objectives of SNP Training

• Review NCQA’s year-to-year approach to the project and reporting requirements for

SNPs

• Describe the changes in the S&P measures for the 2013 SNP Assessment

• Explain how NCQA assesses plans’ performance with individual elements in the S&P Measures

SNP Training – SNP Structure & Process Measures 1 thru 3

2

Objectives of SNP Assessment Program

• Develop a robust and comprehensive assessment strategy

• Evaluate the quality of care SNPs provide

• Evaluate how SNPs address the special needs of their beneficiaries

• Provide data to CMS to allow plan-plan and year-year comparisons


3

SNP Assessment: How did we get here?

• Existing contract with CMS to develop measures focusing on vulnerable elderly

• Revised contract to address SNP assessment

2008 - rapid turnaround, adapted existing NCQA measures and processes from Accreditation programs

2009 - focused on SNP-specific measures

2010 - refined existing measures

2011 - clarified requirements in SNP 1 thru 6

2012 - refined measures and documentation requirements; focus on implementing interventions


4

Who Reports

• HEDIS measures

– All SNP plan benefit packages with 30 or more members as of February 2012

Comprehensive Report (CMS website)

• S&P measures

– All SNP plan benefit packages

– Plans with zero enrollment as of April 2013

Comprehensive Report are exempt for certain elements


5

SNP Reporting

• Returning SNPs— all SNPs that were operational as of January 1, 2012 AND renewed for 2013 AND have previously submitted.

– SNP 1 A-G, SNP 2A-C, SNP 3-6

• New SNPs — all SNPs operational as of

January 1, 2012 AND renewed for 2013

AND are reporting for the first time.

– SNP 1 A-D, SNP 2A-C, SNP 4-6


6

Project Time Line – 2013-2014

• June 2013 through September 2013- Training for

SNPs

• June & July 2013 - Release S&P Measures in hardcopy and ISS Data Collection Tool

• October 15, 2013 - S&P Measure submissions due to NCQA

• October 15, 2013 to April 30, 2014 – S&P reviews conducted by NCQA and surveyors

• June 2014 - NCQA delivers SNP Assessment

Report to CMS


7

Structure and Process Measures

SNP 1: Care Management and

Coordination

SNP 1- Care Mgmt. and Coordination

Changes since 2012

• Replaced elements of Complex Case

Management with new ones for Care

Management that assess whether SNPs have appropriate programs to coordinate services and help all members access needed resources

• Better align with CMS MOC requirements for assessment and care plans


10


Changes continued

Care Mgmt. and Coordination consists of Elements

A: Care Management Program Description

B: Population Description

C: Care Management Process

D: Individualized Care Plan

E: Satisfaction with Care Management

F: Analyzing Effectiveness/Identifying Opportunities

G: Implementing Interventions and Follow-up

Evaluation


11


Definition - Care management is a set of activities designed to assist patients and their support systems in managing medical conditions and related psychosocial problems more effectively, with the aims of improving patients’ functional health status, enhancing coordination of care, eliminating duplication of services and reducing the need for expensive medical services.


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Element A Program Description

The SNP has a description for its Care Mgmt. program that includes:

1.

Evidence used to develop the program

2.

Criteria for identifying members who are eligible for the program

3.

Services offered to eligible members

4.

Defined program goals

Data source: documented process


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• Care Mgmt. program focuses on member-specific activities and the coordination of services; it involves:

– Comprehensive assessment of member’s condition

– Determining benefits/resources

– Developing and implementing a care plan that includes performance goals, monitoring and follow-up


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A SNP must have a Care Mgmt. Program

• Based on the subpopulations within its membership SNPs may have the following within a larger Care Mgmt. Program:

– Complex case mgmt

– Transitional case mgmt

– High-risk/high utilization programs

– Hospital case mgmt


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• Factor 1 requires the SNP to describe the evidence it used to develop the program.

– E.g., clinical practice guidelines; scientific evidence from clinical or technical literature or government research; or literature reviews for nonclinical aspects of the program like dealing with or promoting behavioral change.

• Program description must also detail the criteria SNP uses to identify eligible members for factor 2


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• SNP’s description includes the services it provides to members.

• Org that stratifies members based on risk or level of need must include eligibility criteria, services to be provided and goals for each tier.

• Program description also needs to include goals that reflect specific objectives and targets.


17


Element B – Population Assessment

• Annually SNP must:

1.

Assess the characteristics and needs of member population and pertinent subpopulations

2.

Review and update Care Mgmt. processes to address member needs

3.

Review and update Care Mgmt. resources to address member needs

Data source: Documented process


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• Population assessment includes SNP’s covered population not just members in specific programs like CCM

• Documentation must show how:

– SNP considers specific member characteristics when designing and revising program e.g.,

• Medicaid eligibility categories

• Nature and extent of carved out benefits

• Type of SNP

• Race/ethnicity and language preferences


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• Population assessment procedures also need to include consideration of program characteristics and resources e.g., staffing ratios, clinical qualifications, job training, external resources and cultural competency

• SNP’s documentation needs to be dated after 10/15/12


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Element C - Care Mgmt. Assessment Process

• Includes all info for SNP to assess members’ needs and develop interventions for them

• A SNP’s documentation must address all 8 factors

• It may submit assessment tools or screenshots as evidence, if these documents demonstrate the system has all required functionality

Data sources: Documented process and reports or materials


21


SNP’s evidence must include:

• Documentation of clinical history and meds

– e.g., disease onset, inpatient stays, treatment history

• Initial assessment of:

– health status & comorbidities

– activities of daily living

– mental health status and cognitive function

• both aspects are required


22


• Evaluation of:

– cultural and linguistic needs

• review of language needs meets factor 5

– visual & hearing needs, preferences/limitations

– caregiver resources

• e.g., family involvement in decision making

– available benefits

• covered by SNP, carved out for supplemental services such as community behavioral health or national and community resources


23


Element D - Individualized Care Plan

• SNP uses info from assessment e.g., HRAs and other sources to develop a comprehensive care plan

• Care plan includes info on actions or interventions and their duration a SNP’s

Interdisciplinary Care Team (ICT) takes to address members’ medical, BH, functional and support needs.

Data sources: Documented process and reports or materials


24


• A SNP’s documentation shows that the ICT develops a care plan for each member that includes:

– prioritized goals that reflect member’s or caregiver’s preferences and involvement

– self-management plan

– schedule for follow-up/identify barriers

– process to assess member progress


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• Based on the member’s specific needs the care plan also identifies:

– resources to be utilized and appropriate level of care

• CMs as members of the ICT often facilitate referrals to other providers as part of member’s benefits

– planning for coordination of care including transitions and transfers

• identifying how and when ICTs follow up with a member after referral to a health resource

– collaborative approaches to be used


26


Element E - Satisfaction with Care Mgmt

Intent is for SNP to obtain feedback on its Care

Mgmt. program from a broad sample of members, not just those that contacted it

• SNP must submit a report showing it performed an evaluation of satisfaction by:

1) Obtaining feedback from members

2) Analyzing member complaints and inquiries

Data source: Reports


27


Factors 1 and 2 require SNPs to use:

• focus groups or satisfaction surveys that are specific to Care Mgmt program

– e.g., assess satisfaction with--program staff, the usefulness of info received, member’s ability to adhere to recommendations.

• analysis of complaint and inquiry data after

10/15/12 to identify patterns or trends

– quantitative and qualitative


28


• Factors 1 and 2 focus on satisfaction with the Care Mgmt. Program not satisfaction with the SNP’s overall operations

• Reports with data obtained from CAHPS or general surveys will not meet the intent

• Results from satisfaction surveys administered across multiple SNPs must be stratified at individual plan level for analysis


29


• Factor 2 is NA if SNP provides evidence

(e.g., tracking mechanism) showing it did not receive any Care Mgmt. complaints and inquiries after 10/15/12

• Factors 1 and 2 are NA for SNPs that did not have any members at the start of the look-back period, per the CMS April 2013

Comprehensive Report.


30


Element F - Analyzing Effectiveness/

Identifying Opportunities

• The SNP measures the effectiveness of its Care

Mgmt. program using three measures. For each measure, it:

1) Identifies a relevant process or outcome

2) Uses valid methods that provide quantitative results

3) Sets a performance goal

4) Clearly identifies measure specifications

5) Analyzes results

6) Identifies opportunities for improvement, if applicable

Data source: Reports


31


SNP’s report must contain appropriate measures likely to have significant and demonstrable bearing on all or a subset of Care Mgmt. members

– Outcomes based

– Relevant to target population

– Valid methodology

• Contains info on sampling (if used) and sample size calculation

• Measurement periods reflect the effects of seasonality

– Denominator specific to Care Mgmt. population


32


Report shows appropriate analysis – goes beyond simple reporting or data display

– Comparison to goal or benchmark

• Measure must not have exceeded goal from outset

– Quantitative and qualitative

– Opportunities for improvement

• SNP can use 3 patient experience measures

• e.g., improved quality of life, pain management and health status

• May only use 1 satisfaction measure with Care

Mgmt. program operations


33


• Scoring is based on an average for all 3 measures

• Analysis of measures must be SNPspecific. Org can present aggregate analysis if it breaks out data and results for individual SNPs

• SNP must have performed analyses of measures after 10/15/12

• SNPs that submit Care Mgmt. worksheets also need to provide actual reports


34


• Factor 6 is NA if a plan’s documentation confirms it does not have any opportunities for improvement

• Factors 1 thru 6 are NA for SNPs that did not have any members at the start of the look-back period, per the CMS April 2013

Comprehensive Report.


35


• Examples of measures

– HEDIS measures of effectiveness for chronic conditions

• e.g., controlling high blood pressure, persistence of beta blocker treatment after a heart attack

– SF-36 or SF-12 results

– Use of service measures for which consensus indicates improvement – e.g., reduced ED visits

– Readmission rates

– Ambulatory-care sensitive admissions


36


Element G - Implementing Interventions and

Follow-up Evaluation

• Based on the results of its measurement and analysis of Care Mgmt. effectiveness, the organization:

1) Implements at least one intervention for each of the three opportunities identified in

Element F to improve performance

2) Develops a plan for evaluation of the intervention and re-measurement

Data source: Documented process and Reports


37


• Scoring is based on an average for all 3 measures

• Interventions must have been implemented after 10/15/12

• A SNP’s documentation needs to show that it developed a plan to evaluate the effectiveness of its interventions; this evaluation includes re-measurement using methods consistent with initial measurement.


38


• Factor 1 may be NA if no opportunities

• Factor 2, re-measurement, must be completed whether there are opportunities or not.

• SNPs that did not have any members at the start of the look-back period, per the

CMS April 2013 Comprehensive Report receive an NA for factors 1 and 2.


39

Delegation

• We contract with other entities (medical groups) to perform a number of the functions assessed by the Structure and Process measures. How should we demonstrate performance with these requirements?

– Your organization needs to provide the appropriate evidence from these contracted entities to document their performance. In addition you should discuss the details of this documentation with a member of the

SNP Team.


40

About Documentation

• Only attach documentation to the survey tool that fulfills the requirements and contains direct evidence of performance

• Make sure your documentation shows that your SNP meets the intent of each factor/element

• Please provide context to the documentsroadmap/explanation of documentation


41

Questions?


42

SNP 2: Improving Member Satisfaction

Summary of Changes for 2013

• SNP 2 Elements A and B

– Now applicable to both initial and returning

SNPs

• SNP 2 Element C

– Added new example for factor 2 that emphasizes continuing the intervention and then re-measuring if an organization does not meet its initial goal


44

SNP 2: Overview

• Who reports?

– Initial and returning SNPs are responsible for reporting all of SNP 2. This includes Elements

A, B and C

– SNPs that did not have any members at the start of the look-back period will receive a score of NA for the measure

• Per the CMS April 2013 SNP Comprehensive Report


45

SNP 2 Element A

Assessment of Member Satisfaction

• a SNP must supply BOTH a documented process and a report explaining how it performed the assessment and an analysis of member satisfaction data that shows it:

– identified the appropriate population

– selected appropriate samples from the affected population, (if used)

– conducted an quantitative and qualitative analysis annually

• The SNP will receive credit for factor 2 if it collects data for its entire population


46

SNP 2 Element A

• A SNP’s complaint and appeal data must relate to at least the four major categories

– Quality of Care

– Access

– Attitude and Service

– Billing and Financial

• It must submit a report that shows the quantitative and qualitative analyses were performed after 10/1/12.

• Complaint, grievance and appeal data or satisfaction survey data collected more than 12 months prior to the start of the look-back period--(4/15/12) will not meet the intent


47

SNP 2 Element A

• All SNP complaint/appeal data must be at the PBP level. The SNP should receive a score of:

– 50% for data only identified as “Medicare”

– 0% if data source is not specified at all

• SNPs must perform their own analysis of

CAHPS results, not just attach a vendor’s report to meet the intent of Element A.


48

SNP 2 Element A

• If the SNP has no complaints, appeals or grievances, it must still show a table, spreadsheet or other documentation that demonstrates it collected appropriate data for an analysis and found no complaints or appeals for its members


49

SNP 2 Element A

• The analysis must be SNP-specific; plans must break out the data at the PBP level for an aggregate analysis of complaints and appeals across multiple benefit plans


50

SNP 2 Element B

Opportunities for Improvement

• Element B requires a SNP to show:

– How it identifies opportunities for improvement of member satisfaction (documented processes)

– At least 2 opportunities for improvements based on its data and analysis for SNP 2A (reports)

– It identified opportunities after 10/1/12.

• Analysis should indicate reasons for opportunities identified

– May be lesser priorities


51

SNP 2 Element B

• Element B is NA if:

– a SNP’s analysis does not result in the identification of one or more opportunities for improvement.

• Reasons for no improvement opportunities may include:

– no or very low enrollment

– no trendable data available

– very low number of complaints/appeals


52

SNP 2 Element C

Improving Satisfaction

• Element C requires a SNP to show that it is actively working on implementing interventions and measuring their effectiveness.

– Plans must provide BOTH documented processes and reports

• The interventions must relate to opportunities identified in SNP 2B

• Do not have to show improvement on interventions, but a SNP must show it measured intervention effectiveness.


53

SNP 2 Element C

• Timeframes

– Interventions must be implemented within one year of the submission date (October 15,

2012 – October 15, 2013)

– Analysis of intervention effectiveness or remeasurement for those that do not have opportunities must be performed within the look-back period (April 15, 2013 – October

15, 2013)


54

SNP 2 Element C

• When evaluating intervention effectiveness for factor 2 - SNPs must perform remeasurement against an original goal, or a targeted intermediate measurement of specific interventions


55

SNP 2 Element C

• If a SNP has no members as of the start of look-back period, then this element is

“NA”.

– Per the CMS April 2013 SNP Comprehensive

Report

• Initial SNPs with no opportunities for improvement get an “NA” for factors 1-2

• Returning SNPs with no opportunities for improvement get an “NA” for factor 1 only


56

Polling Question


57

Polling Question

• True or false.

– For SNP 2 Element C, a returning SNP will be scored “NA” for factor 2 if the analysis of satisfaction data shows it does not have opportunities for improvement


58

SNP 3: Clinical Quality Improvement

SNP 3 Element A

• Methodology has been revised to calculate statistically significant improvement. The new methodology better addresses the “small numbers” issues related to low enrollments and denominators for many of the HEDIS measures and more accurately reflects year-to-year improvement without penalizing plans.

• SNPs that do not have 30 members as of the

CMS February 2012 SNP Comprehensive Report are exempt from reporting this measure and receive a score of “NA.”


60

SNP 3 Element A

• What is statistical significance?

– 0-59: At least a 6 percentage point change






• This applies to measures where both higher and lower percentages are better


61

SNP 3 Element A

• Which SNPs must demonstrate clinical improvement?

– Only returning SNPs will be scored

– Initial SNPs and plans with <30 members (as of

Feb 2012 CMS Comp. Report) are exempt

• Plans are not required to submit anything in ISS. NCQA will score this element internally.


62

Questions?


63

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