Special Needs Plan-Model of Care
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History of the SNP
The Medicare Prescription Drug, Improvement, and
Modernization Act of 2003 (MMA) authorized the creation of a
type of Medicare Advantage (MA) plan referred to as a Special
Needs Plan (SNP), to address the unique needs of certain
Medicare populations.
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There are 3 categories of SNPs
D-SNP (Dual Eligible; individuals who qualify for both
Medicare Part A and Part B and full Medicaid benefits)
I-SNP (Institutionalized; for individuals residing in nursing
facilities or institutions)
C-SNP (Chronic condition; for individuals with severe or
disabling chronic conditions)
ATRIO’s SNP beneficiaries are all classified as D-SNPs. DSNPs are the only kind of SNPs that ATRIO currently offers.
In addition to meeting all the requirements of other MA plans,
all SNPs, including D-SNPs, are required by the Centers of
Medicare and Medicaid Services (CMS)---the agency in the
Department of Health and Human Services (HHS) that
administers Medicare and oversees Medicaid—to provide
specialized services targeted to the needs of their
beneficiaries, including a health risk assessment and an
interdisciplinary care team for each beneficiary enrolled.
SNPs, including D-SNPs, have been reauthorized several
times since their establishment was first authorized in 2003.
For example, the Medicare Improvements for Patients and
Providers Act of 2008 (MIPPA) and the Patient Protection
and Affordable Care Act (PPACA—effective January 1,
2012) both contain provisions reauthorizing and modifying
SNPs.
CMS requires D-SNPs to develop a model of care (MOC)
that describes their approach to caring for their target
population. The SNP MOC is a working framework (“the
promise”) indicating how the SNP proposes to coordinate the
care of SNP enrollees.
The MOC in years past has included 11 Elements and for
CY2015—NCQA & CMS have revised the MOC
requirements to include 4 sections with a total of 15 elements.
The 4 sections are:
MOC 1: Description of SNP Population
MOC 2: Care Coordination
MOC 3: Provider Network
MOC 4: MOC Quality Measurement and Performance Improvement
It is a CMS requirement that all employed and contracted
staff who provide indirect and direct care coordination
services to SNP members complete an initial SNP MOC
training as well as annual SNP MOC training thereafter.
ATRIO will provide the annual SNP MOC training for all
employed and contracted staff and maintain the
documentation of completion of that training as required.
MOC 1: Description of SNP Population
A comprehensive description of ATRIO’s SNP-specific
population that addresses the full continuum of care for
current and potential SNP beneficiaries and describes the
specially tailored services for these most vulnerable members.
The description includes social, cognitive, environmental,
living conditions and medical and health conditions including
co-morbidities of ATRIO’s SNP population.
Demographic Breakdown of ATRIO’s SNP Population
Gender
Age Range
89-105
5%
12-38
10%
male
41%
female
59%
*Data as of January 2014
39-63
39%
64-88
46%
Vietnamese
1%
Language
Unidentified 4%
Cantonese
0.02%
Ethnicity
Native
American
2%
Asian
2%
Hispanic
6%
Unidentified
34%
English
58%
Spanish
5%
Sign
Language
0.10%
Laotian
0.02%
Caucasian
85%
Korean
0.02%
Russian
2%
AfricanAmerican
1%
Low Income Subsidy Co-Pay Category
1
17%
3
50%
2
33%
MOC 1 then goes on to detail the specially tailored services ATRIO provides to its
most vulnerable members and established relationships with partners in the
community to provide needed resources.
Services and programs include:
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TOC program (Transitions of Care)
CCM program (Complex Case Management)
ICT activities (Interdisciplinary Care Team)
CHE programs (Comprehensive Home Evaluations)
QIPs (Quality Improvement Programs)
CCIP (Chronic Care Improvement Program)
Medication Therapy Management
Overutilization of Opioids Pharmaceutical Program
CCSMP/Living Health Program (Chronic Care Self-Management Program)
Community partnerships include:
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OHP (Oregon Health Plan) including the SAC CCOs
Clinical Advisory Panels
Service area Behavioral, Mental & Addiction Health Organizations
DHS (Department of Health and Human Services)
Home Health Care Agencies
DME Companies
Service area Pharmacies
Service area Provider practices
Palliative and Hospice Care Services
Service area Hospitals
Transportation Services
Various not-for-profits
Adult Foster Homes
Skilled Nursing Facilities
Assisted Living Facilities
Rehabilitation Facilities
Mental Health Inpatient and Outpatient Facilities
Specialty Pain Clinics
Meals on Wheels
*For more details of what these programs and partnerships consist of please refer to ATRIO’s SNP MOC; MOC 1; Element B.
MOC 2: Care Coordination
Helps ensure that SNP beneficiaries’ health care needs,
preference for health services and information sharing across
the health care staff and facilities are met over time. Care
coordination maximizes the use of effective, efficient, safe,
high-quality patient services that ultimately lead to improved
health care outcomes.
The first Element A of MOC 2 is all about the SNP Staff
Structure. There has at times been a misconception that care
coordination consists of only the nurses and specifically the
SAC (Service Area Contract) NCM (Nurse Case Managers)
and this is not at all accurate.
With over 5000 SNP members it takes much more than the
efforts made by the SAC NCMs to coordinate care services
for our SNP members.
Element B of MOC 2 addresses the HRAT (Health Risk
Assessment Tool). The HRA is a comprehensive document
used by the Plan to identify the specialized needs of its
beneficiaries and to coordinate care that reflects the member’s
personal preferences. The HRA questionnaire assesses
medical, psychosocial, cognitive, and functional needs as well
as the SNP member’s medical and mental health history.
The SAC NCMs and other ICT members use the HRAs to
develop ICPs (Individualized Care Plans) by assisting in the
identification of prioritized needs, specific goals and
appropriate interventions.
Per CMS requirements each SNP member is sent an initial
HRA at the time of a new enrollment and annually thereafter.
Home visits in the form of CHEs (Comprehensive Home
Evaluations) are also conducted on a regular basis to collect
HRA information on high risk SNP members. SNP members
who are unable to complete the written form of the HRA or
participate in a CHE can also always request HRA completion
assistance over the phone with one of our NCMs.
Element C of MOC 2 addresses the ICP (Individualized Care
Plan). ATRIO has adopted the CMS definition of a care plan
meaning “a set of information about the patient that facilitates
communication, collaboration and continuity of care across
settings”.
ATRIO has developed a customizable ICP within the
designated case management software (TCS Acuity).
The components of this ICP include:
• SNP member demographic information including contact
information
• Primary Care Provider & contact information
• A list of other providers the member has seen in the past 12
months
• Current health insurance coverage and eligibility
information
• A list of allergies
• A list of medications
• A list of care diagnoses
• A Case Management note from the assigned NCM
• A list of active goals and associated interventions
• A list of ICT members
ATRIO delegates the responsibility of development and
management of the ICP to the SAC assigned NCM. The ICPs
are contained within the case management software and are
generated using SNP member specific information from a
variety of sources including but not limited to: claims, the
HRA, CHE, medical records and information gathered by the
NCM and other ICT members from the SNP beneficiary
and/or caregiver(s). The case management software serves as
the central location for the documentation of care
management and care coordination activities.
Element D of MOC 2 addresses Interdisciplinary Care Teams
(ICT). ATRIO has adopted the CMS definition of an
Interdisciplinary Care Team to refer to “a team of
professionals from multiple disciplines who work together to
coordinate and facilitate patient focused care”.
ATRIO delegates this process to its Service Area Contractors
(SAC). Each SAC is responsible to follow the specific
ATRIO ICT policy and procedure (located within the SNP
CM Policy and Procedure) as well as the framework outlined
in the SNP MOC. SNP members are assigned to a NCM
within their service area. NCMs take the lead in the
responsibly of forming the ICTs for SNP members.
ICTs will at a minimum and whenever feasible include the
assigned NCM, the SNP member and/or primary caregiver
and the member’s PCP.
The final Element E of MOC 2 addresses Care Transitions
Protocols. ATRIO has adopted the following CMS
definitions used to explain care transitions:
Health care settings:
The provider from whom or setting where a member receives health care
and health-related services. In any setting, a designated practitioner has
ongoing responsibility for a member’s medical care.
Transition:
Movement of a member from one care setting to another as the member’s
health status changes. For example, moving from home to a hospital as the
result of an exacerbation of a chronic condition or moving from the
hospital to a rehabilitation facility after surgery.
Transitions process:
The period of identification of a member who is at risk for a care
transition through completion of a transition. This process includes
planning and preparation for transitions and the follow-up care after
transitions are completed.
ATRIO makes special effort to coordinate care when SNP members move
from one health care setting to another, such as when they are discharged
from a hospital. Without coordination, such transitions often result in
fragmented and unsafe care for the older or disabled and particularly
vulnerable SNP beneficiary. ATRIO’s Transitions of Care program is
designed with the intent to minimize risks associated with health care
transitions.
ATRIO delegates the responsibility of coordination of the care transitions
processes to the SAC assigned NCMs. Each SAC is responsible to follow
the specific ATRIO TOC policy and procedure (located within the SNP
CM Policy and Procedure) as well as the framework outlined in the SNP
MOC. The case management software serves as the central location for
the documentation of care management and care coordination activities
including the care transitions processes.
MOC 3: Provider Network
The SNP provider network is a network of health care providers who are
contracted to provide health care services to SNP beneficiaries. SNPs
must ensure that their MOC identifies, fully describes and implements the
following element for their SNP provider network: Specialized Expertise,
Use of Clinical Practice Guidelines and Care Transitions Protocols and
MOC Training for the Provider Network.
ATRIO has established a vast network of providers and healthcare
facilities allowing the Plan to provide exceptional access and care services
to the often vulnerable SNP beneficiaries. ATRIO regards the primary
care provider (PCP) as the expert in determining the health care needs of
the SNP beneficiary. Each SNP member is required to have an identified
PCP and our SAC NCMs, Customer Service Representatives and Provider
Relations staff make special effort to match SNP members with a PCP
they can be most aligned and satisfied with.
In addition to our extensive network of primary care providers
ATRIO has established an equally robust network of specialty
and ancillary care providers for our SNP members.
These include:
Medical Specialists: Allergy & Immunology, Anesthesiology, Audiology,
Cardiology, Chiropractic, Dermatology, Dietary, Endocrinology,
Gastroenterology, Gerontology, Gynecology, Infectious Disease,
Nephrology, Neurology, Obstetrics/Gynecology, Oncology,
Ophthalmology, Oral Surgeon, Orthopedics, Otolaryngology, Pain
Management, Podiatry, Psychiatry, Pulmonology, Rheumatology, and
Urology
Behavioral & Mental Health: Drug Counselors, Clinical Psychologists,
Licensed Clinical Social Workers and other mental health professionals
Nursing professionals: Registered Nurse and Nurse Practitioners
Allied Health Professionals: Pharmacies, Physical Therapists,
Occupational Therapists, Speech Therapists, Pathology, Radiology
Specialists and Hospice care givers and coordinators
Facilities: Inpatient, Outpatient, Rehabilitative, Long Term Care,
Psychiatric, Laboratory, Radiology/Imaging, Dialysis, Home Health,
Urgent Care, Durable Medical Equipment Supplier.
MOC 4: MOC Quality Measurement and Performance
Improvement
The goal of performance improvement and quality
measurement is to improve the SNP’s ability to deliver highquality health care services and benefits to its SNP
beneficiaries. Plan leadership, managers and governing bodies
of the SNP organization must have a comprehensive quality
improvement program in place to measure its current level of
performance and determine if organizational systems and
processes must be modified, based on performance results.
ATRIO has a quality improvement process by which various
data sets collected from multiple sources are used to evaluate,
measure, stratify and report on the Plan’s Full-Dual Special
Needs Plan Model of Care. The Quality Assurance Committee
with authority from the Board of Directors is responsible for
monitoring and evaluating the SNP MOC effectiveness.
The QA Committee is charged with:
• Recommend outcomes to be monitored and establish benchmarks for
ongoing monitoring and oversight of the SNP MOC.
• Evaluate the timeliness and response rate of the HRAs for SNP
beneficiaries’ participation in the creation/management of
individualized care plans.
• Annually evaluate the associated HEDIS, CAHPS and HOS data
results
• Assist in the identification of the most vulnerable SNP beneficiaries
• Evaluate the Plan’s ability to effectively communicate the results and
effectiveness of the MOC to all stakeholders and recommend enhanced
training if need be.
• Recommend improvements to the SNP MOC and the evaluation
process
ATRIO’s MOC measurable goals and health outcomes revolve around the
areas of access to care services, affordability, coordination of care, care
transitions and utilization of services for preventative health and chronic
conditions.
The following are ATRIO’s current measurable goals:
Measurable Goal—ATRIO will achieve a score of ≥ 84% on annual
CAHPS results for the following questions.
• Ease of getting an appointment with a specialist
• Getting care, tests, or treatment necessary
Measurable Goal—ATRIO will achieve a ≥4 Star rating for the MPF
(Medicare Pharmacy Finder) price accuracy measure.
Measurable Goal—ATRIO will achieve a score of ≥85% on annual
CAHPS results for the following questions
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Doctor had medical records or other information about your care
Doctor talked about prescription medicines
Got help managing care
Doctor informed and up-to-date about specialty care
Measureable Goal—ATRIO will achieve a ≥3 star rating for the HRA
return rate (SNP Care Management Star Measure)
Measurable Goal—ATRIO will achieve a ≥4 star rating for Plan AllCause Readmissions (readmissions to a hospital within 30 days of being
discharged)
Measureable Goal-- ATRIO will achieve a ≥3 star rating for Diabetes
Care—Cholesterol Screening
Measurable Goal—ATRIO will achieve a ≥3 star rating for Osteoporosis
Management.
ATRIO operates under a continual process of quality
improvement for all of our programs and especially those
directly involving our most vulnerable SNP members.
ATRIO’s QA Committee and SNP Leadership prioritize
mechanisms of improvements to the SNP MOC and respond
to lessons learned and implement those improvements in as
timely a manner as possible with the end goal of assisting our
SNP members in achieving the highest level of quality care.
For more information on any of the topics included here please
refer to ATRIO’s full copy of the SNP MOC.
If you do not currently have a copy of ATRIO’s SNP MOC and
would like one for your reference please make a request from
ATRIO’s SNP Program Manager who can be reached via
ATRIO’s Customer Service Department at 1-877-672-8620.
Customer Services hours are Monday-Friday 8 am- 5 pm Pacific
Time