1
Sharing Best Practices for Special Needs Plans
GuildNet
Laura Brannigan, BS, BSN, MA
Senior Vice President
Quality Improvement
January 13, 2013
About GuildNet
• 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
2
3
Jewish Guild Health Care: Vision + Services
• Low Vision Clinic
• Medical Services- DTC
• Diabetes Care
• GuildCare – Adult Day Health
Care
• Workplace Technology
• Psychiatric Clinic
• GuildNet – Managed Long
Term Care
• Mental Health Day Treatment
• GuildNet Gold – Medicare
Advantage SNP
• Developmental Disabilities
Day Treatment
• GuildNet Health Advantage
• Crisis Counseling
• GuildNet Gold Plus
• Independent Living Skills
• SightCare
• Bressler Prize
• GuildScholar Award
• Guild School
• Children’s Vision Health
Initiative
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
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
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
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
Structure
• Zero cost share plans
• Provide integrated Medicare and Medicaid
services
• Primary point of contact for members
• Role of additional GuildNet Departments
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
PCP
Home
Health Aide
IDT
Hospital/LTC/
Facilities
Participant/Participant
Designee
HealthCare
Professionals
(OT, PT, MH,
CHHA)
Pharmacy
Community
Services
11
Care Coordination Strategies
ONGOING COMMUNICATION BETWEEN IDT AND PARTICIPANT VIA
TELEPHONE USING THE PARTICPANT’S PREFERRED LANGUAGE
6 MONTHS FROM ENROLLMENT
PRE-ENROLLMENT
In home visit occurs by RN
prior to enrollment
PSCP developed
WITHIN 2 WEEKS
Mental Health/Social Worker
contacts member to assess
Care Manager calls
Particpant to discuss PSCP
In home Reassessment occurs
using HRA tool
PSCP updated using HRA score
and input from Participant
12
Process Flow Overview
ASSESS
Member screened using a Health Risk Assessment tool , interview call from Case Manager and/or
In home Assessment
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
ACT
1) Evaluate current benefits and available community resources
2) Deploy referrals, services and resources to implement care plan
13
Process Flow Overview Cont’d
COMMUNICATE
1) Mail/Fax Care Plan to member's PCP
2) Mail Care Plan to Member/Caregiver
FOLLOW UP
1)Follow up with member/caregiver and provider within the specified timeframe
2) Assess progress to goals and additional barriers
REVISE OR CONTINUE
Revise Plan as needed, adjust resources and referrals and communicate to IDT team and
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
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
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
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: branniganl@guildhealth.org
Visit our Website for more information about GuildNet:
www.guildhealth.org