INSTITUTIONAL SPECIAL
NEEDS PROGRAM
Best Practices in Care Coordination and
Care Transitions
Beth Ann Martucci, DNP, CRNP
Director of Clinical Operations
January 13, 2014
TARGET POPULATION
• Institutionalized Medicare beneficiary who resides or is expected to
reside in a Cigna-HealthSpring contracted skilled nursing facility for
90 days or longer.
• I-SNP membership:
– Largely female, cognitively impaired, in fair to poor health due to
multiple chronic illnesses, low income and over the age of 81.
– Top 5 admitting diagnoses: pneumonia, respiratory failure, UTI,
CHF, altered mental status
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I-SNP PROGRAM SNAPSHOT
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Total # of institutional-based members: 1,256
Total # of Cigna-HealthSpring contracted facilities: 42
I-SNP Nurse Practitioner Case Managers: 24
Dedicated I-SNP Care Coordination Team: 4 Care Coordinators
I-SNP RN Case Manager: 1 (pilot program completed in December
2013)
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RISK ASSESSMENT TOOL
• The clinical team provides integrated health care management with a
strong primary and preventive care focus to treat acute and chronic
conditions.
– All I-SNP members receive a comprehensive history and physical
exam and care plan within 30 days of enrollment and
comprehensive visits at least once a month, thereafter. Care
coordination and care transitions support is provided to all
members, as needed.
• Nurse Practitioners (NPs) utilize a risk assessment tool that rates
each member’s medical condition on a scale of 1-5: Level 1-HOT,
Level 2 and 3- WARM, Level 4 and 5-COLD
– Risk score dictates the NP’s visit schedule
– Average NP visits per day – 8
– Risk score framework used at each visit and tracked over time via
encounter data
Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2014 Cigna
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CARE TRANSITIONS PROCESS
• The Cigna-HealthSpring NP, PCP and the member’s caregiver are to be
notified of every acute care transition. Prior to the member’s transition, the
SNF completes a checklist/packet that includes: the member’s
comprehensive history and physical notes, the most recent comprehensive
or episodic note, consult notes, the medication list, and advanced directives.
• Upon return to the SNF, the NP must see the member within 1 business day.
A comprehensive visit is performed; discharge summary is reviewed and
signed; medication reconciliation is performed and a call is placed to the
caregiver and PCP. If the NP is unable to reach the caregiver, a postcard
note is sent to the caregiver with the NP’s contact information.
• During the weekly plan-level Interdisciplinary Care Team (ICT) call, the
dedicated NP assigned to the hospitalized member updates the ICT on the
member’s status and transition plan.
Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2014 Cigna
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MONITORING CARE TRANSITIONS
• Daily Hospitalization Report
– Used to track transitions over time. Updated by the NP when a
transition occurs.
• Unplanned Transition Audit Tool
– Completed by the NP Senior Clinician on each member that has
had an unplanned transition and reviewed monthly with SNF
administration team.
Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2014 Cigna
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IMPROVING OUTCOMES
• Plan-level Interdisciplinary Care Team (ICT): Medical Director from each
market, Nurse Practitioners, pharmacist from each market, RN Case
Managers.
• Daily NP management call to discuss happenings at the facility level.
• Weekly conference call with the plan-level ICT to discuss HOT, skilled
and hospitalized members. Also review care plans for at risk members.
• Care Plan Conferences with NP, facility staff and member/caregiver, as
appropriate.
• Weekly meetings with the Care Coordination team to improve
processes/efficiencies, improve level of customer service and
communication.
• Monthly mandatory NP meetings – case presentations, educational inservices including best-practices/evidence based practices.
Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2014 Cigna
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MONITORING PROGRAM PERFORMANCE
• Measurable outcomes are monitored by measuring, reporting, and
base-lining/goal-setting or benchmarking to standards for the
following activities:
– Completion of a comprehensive history and physical with the ICP
within 30 days of enrollment and annually thereafter.
– Completion of a monthly comprehensive visit on all members.
– Care coordination (arranging for authorizations, appointments and
transportation within turn around time: Immediate: same day;
Urgent: 2 days; Standard:14 days.
Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2014 Cigna
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MONITORING PROGRAM PERFORMANCE - CONTINUED
– NP notification prior to un-planned discharge from the SNF to an
acute setting
– Re-admissions to an acute setting within 30 days
– HEDIS measures
These clinical and service operations metrics are measured and
reported to Cigna-HealthSpring’s executive management team
monthly in a Key Performance Metrics report. The Market Manager
and Chief Operating Officer take direct responsibility for ensuring
remediation plans are fulfilled.
Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2014 Cigna
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