SNP 4 Element A

Report
SNP 4 through 6 Training
July 18, 24 and 30, 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 4 through 6 Training
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
SNP 4 through 6 Training
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
SNP 4 through 6 Training
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
SNP 4 through 6 Training
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
SNP 4 through 6 Training
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
SNP 4 through 6 Training
7
Structure and Process Measures
SNP 4: Care Transitions
SNP 4: Care Transitions
• Focuses on coordination of information
related to transitions of care from one
setting to another (e.g., hospital to home)
• Identify “at-risk” members and take
actions to prevent or reduce unplanned
transitions
– Coordinate services
– Educate members
SNP 4 through 6 Training
10
What’s Changed?
• No major content, documentation or scoring
changes
• Element E—Added a new factor that requires
plans to take actions or interventions related to
the opportunities identified in factor 2.
• Element E—clarified that plans may use their
existing CMS QIP related to reducing hospital
admissions to satisfy factor 3 requirements
SNP 4 through 6 Training
11
SNP 4 Element A: Managing Transitions
• Managing & coordinating
planned/unplanned transitions from one
care setting to another
– Factor 1 focuses on planned transitions to and
from a hospital
• Requires SNP to show it is aware that a transition is
about to take place—before it happens and
provide support throughout the transition process,
not just after discharge
• A preauthorization policy included in
documentation must show how it triggers clinical
action. Cannot solely pertain to a coverage or
payment decision.
SNP 4 through 6 Training
12
SNP 4 Element A
• Factor 2 specifies requirements for planned and
unplanned transitions to and from a hospital
• Sending setting must share care plan with
receiving setting within 1 business day of
transition notification
– Care plan consists of patient info that facilitates
communication, collaboration and continuity of care
across settings
– Org determines what info care plan includes
– Must specify practitioner to receive care plan for
planned transitions to hospital—must show evidence
SNP shared care plan with practitioner w/in specified
timeframe
SNP 4 through 6 Training
13
SNP 4 Element A
• Factor 3: Notifying member’s usual
practitioner of transition
– planned and unplanned transitions to and
from all care settings
– must specify a timeframe for completion of
transition activities, e.g.,
• 24-48 hours prior to member movement to
receiving setting
• within 1 business day of member’s discharge
• at least 2 calendar days before the scheduled
procedure
SNP 4 through 6 Training
14
SNP 4 Element B
Supporting Members Through Transitions
• Communications with members/
caregivers within specified timeframes
regarding:
– the transition process and what to expect
– changes in health status and their care plan
– who will support them through the process
• Factors 1 thru 3 pertain to planned and
unplanned transitions to and from all care
settings
SNP 4 through 6 Training
15
SNP 4 Element B
• A SNP’s documented process for factors 1
thru 3 must specify a timeframe for
completion of required transition activities
– The following do not qualify as timeframes
•during the encounter ….
•upon identification of transition needs ….
•regular contact and review ….
•on an ongoing basis ….
•during discharge ….
SNP 4 through 6 Training
16
SNP 4 Element C
• SNPs must include all activities from
Elements A & B in the analysis:
– assess the frequency a SNP performs the
following functions:
• Identify planned transitions
• Share care plan across settings w/in 1 bus. day
• Notify usual practitioner
• Communicate w/ member about transition process
• Communicate w/member about care plan
• Communicate w/member about point of contact
SNP 4 through 6 Training
17
SNP 4 Element C
• The intent of the aggregate analysis for this
element is for plans to assess how well they are
managing transition activities.
• Factors 1 and 3 need to show:
– data collected;
– a quantitative and qualitative analysis; and
– the opportunities for improvement
• Factors 2 and 4 must describe:
– the universe of members in the sample
– sampling methodology
– how the SNP drew at least 3 months of data
SNP 4 through 6 Training
18
SNP 4 Element C
What is an Analysis?
• An evaluation of aggregate performance that
includes:
– quantitative data – number of transitions in the
denominator for a factor and the number of transitions
where the SNP performed the activity specified by the
factor within any pertinent timeframes
– qualitative data – notations on results, trends,
anomalies, assessment of causes/reasons for findings
» identification of opportunities and
recommendations for further action
SNP 4 through 6 Training
19
SNP 4 Element D
Identifying Unplanned Transitions
• A SNP must show that it:
– has a documented process and reviews
reports of hospital admissions within 1
business day of the admission
• Must show at least 3 admissions
– reviews reports of long-term care facility
admissions within 1 business day of the
admission
• Must show at least 3 admissions
SNP 4 through 6 Training
20
SNP 4 Element E
•
Focus of element is on minimizing unplanned
transitions and keeping patients in least
restrictive setting
•
Factor 1 requires an analysis of patient-specific
data to identify those at risk
−
E.g., claims, UM or provider reports, predictive
modeling
SNP 4 through 6 Training
21
SNP 4 Element E
• A SNP’s documentation for factor 1 needs
to show:
– data collected—must monitor all members
– members targeted
– areas where it acts to minimize the risk of
unplanned transitions and keep members in
the least restrictive setting
SNP 4 through 6 Training
22
SNP 4 Element E
Factor 2 requires SNPs to analyze data and identify
areas where avoidable, unplanned transitions can
be reduced
• Analyze member admissions to all hospitals
and ED visits
– Population focus (aggregate data)
– Actual analysis to identify areas for
improvement
SNP 4 through 6 Training
23
SNP 4 Element E
• SNP’s documentation for factor 2 must
show:
1) data collected
2) quantitative and qualitative analysis
3) opportunities for improvement.
• SNP must include in-network and out of
network facilities and EDs in this analysis
for factor 2. If it only includes in-network
facilities, it does not receive full credit for
this factor (cannot score >50%).
SNP 4 through 6 Training
24
SNP 4 Element E
• New clarification!
SNP must provide evidence of 1 analysis
performed after 10/15/12
– Data collected must be dated after 10/15/12
• Analyses must be SNP-specific;
organizations that perform an aggregate
analysis of multiple benefit plans must
break out the data for each individual plan
SNP 4 through 6 Training
25
SNP 4: Element E
• New for 2013: Factor 3—implementing
interventions
• The SNP must implement at least one
intervention from the opportunities
identified in factor 2 during the look-back
period.
– Do not have to show improvement or
effectiveness of the intervention
– SNPs can use their existing CMS QIP related to
reducing hospital readmissions
SNP 4 through 6 Training
26
SNP 4 Element F
Reducing Transitions
Factors 1 and 2 require a SNP’s documentation to
show that it:
• Coordinates services for at-risk members
•
Educates these members or their caregivers
on how to prevent unplanned transitions
Actions must relate to findings from
monthly analyses in SNP 4:E, factor 1
SNP 4 through 6 Training
27
SNP 4 Element F
• Factor 1—Care Coordination may be
done through Case Mgmt or other
programs; SNP must maintain special
procedures if all members are not in CM
• Factor 2—Educational opportunities must
be related to specific, targeted
populations, not just general health
education
SNP 4 through 6 Training
28
SNP 4 through 6 Training
29
SNP 5: Institutional SNP Relationship with
Facility
SNP 5 Element A
Monitoring Members’ Health Status
• Institutional SNPs only
– Focus is on communications with facilities to monitor
member needs and services provided
– Facilities include contracted nursing facilities and
assisted living facilities
• The SNP must show that it monitors information on
members’ health status at least monthly
– Communication should include information that may
indicate a change in health status or no change
SNP 4 through 6 Training
31
SNP 5 Element A
• Scoring
•100% or full credit
– Institutional SNPs who monitor at least
monthly
•50% or partial credit
– Institutional SNPs who monitor at least
quarterly
•0% or no credit
– Institutional SNPs who monitor less often
than quarterly
SNP 4 through 6 Training
32
SNP 5 Element A
• Monitoring methods a SNP can use:
– data derived from MDS or other reports on member
health status it requires from the institutional facility
– reports from its staff who visit members in facilities
– data on members’ health status it collects through care
management if collected on a monthly basis
• Status reports may include:
–
–
–
–
Functional status assessments
Medication regimen
Self-reported health status
Reports on falls, socialization and depression
SNP 4 through 6 Training
33
SNP 5 Element A
• Documentation
– a SNP must provide a documented process
and one additional data source or it does not
receive full credit for this element
• Element is NA for:
– An Institutional SNP that shows it does not have
contracts with nursing facilities or assisted living
facilities
 all members reside in the community
• Dual Eligible and Chronic Care SNPs are exempt
– Score all elements in this measure “NA”
SNP 4 through 6 Training
34
Polling Question
• True or False
An Institutional SNP that only has
contracts with and members residing
in assisted living facilities is exempt
from reporting SNP 5 Element A
SNP 4 through 6 Training
35
SNP 5 Element B
Monitoring Changes in Members’ Health Status
•
Organization monitors and responds to triggering
events and changes by:
1.
2.
3.
4.
Setting parameters for the types of changes and
triggering events contracted facilities must report within
48 hours, 3 calendar days and 4 to 7 calendar days
Identifying who will act on that information and should
be contacted
Identifying how the member’s care will be coordinated
with appropriate clinicians or the clinical care plan
Identifying one monitoring or data collection method it
uses to assess changes in all members’ health status
SNP 4 through 6 Training
36
Factor 1 Details
• An organization must submit evidence that shows it has
identified specific conditions or early warning signs and
symptoms that facilities must report within a minimum of:
 48 hours
 3 calendar days
 4-7 days
• The SNP must submit a documented process and reports
or materials showing how and when facility staff must
report a list of triggers such as:
 changes in vital signs
 changes in the member’s behavior
 changes in their functional status
 complaints of pain
SNP 4 through 6 Training
37
SNP 5 Element B
• Explanation of scoring
•100% or full credit
– The organization meets all 4 factors
•50% or partial credit
– The organization meets 3 factors including
factors 1 through 3 (critical factors)
•0% or no credit
– The organization meets 0-2 factors or does
not meet factors 1, 2 or 3
SNP 4 through 6 Training
38
SNP 5 Element B
• The SNP must demonstrate it monitors
members through one of the following
methods:
– Reports from facilities to the organization such as
Minimum Data Set (MDS)
– Reports from organization staff who visit the
members
– Oversight of facility monitoring and reporting
changes to treating practitioners rather than to the
organization
– A combination of the processes above
SNP 4 through 6 Training
39
SNP 5 Element C
Maintaining Members’ Health Status
• Organizations use the information from SNP 5
Elements A&B to identify at-risk members and
work with facilities/practitioners to arrange
for necessary care and adjust care plans as
needed to prevent declines in member
health status
• Scoring is 100% or 0% (all or nothing element)
SNP 4 through 6 Training
40
SNP 5 Element C
Methods of providing care:
• SNPs may have differing models of relationships
with facilities to address these monitoring
functions
– Facility oversight: relies on facilities to
modify/carry out care plans
– Staff practitioners: SNP staff practitioners visit
facilities and order care plan modifications
– Other models of care: SNPs may use a
combination of above models or different
one
SNP 4 through 6 Training
41
SNP 5 Element C
Documentation
• A SNP must submit:
– Documented Processes; AND
• Policies describing increases in frequency of visits to
member by the organization’s nurse managers to
assess, revise the care plan and monitor his or her
condition after a health status decline and resulting
inpatient stay
– Reports
• Screenshots from the organization’s care
management system documenting monitoring visits,
assessments and care plan changes the nurse
managers discussed with the member’s treating
practitioner and notes confirming the practitioner’s
agreement
SNP 4 through 6 Training
42
SNP 4 through 6 Training
43
SNP 6: Coordination of Medicare and
Medicaid Coverage
What’s Changed?
No major changes in 2013!!!
SNP 4 through 6 Training
45
SNP 6 Element A
Not Applicable for C-SNPs & I-SNPs
Coordination of Benefits for Dual-Eligible Members
Dual-eligible SNPs coordinate Medicare & Medicaid
benefits/services for their members by:
• Giving members access to staff knowledgeable about
both programs
• Providing clear explanations of rights to pursue
grievances/appeals under both programs
• Providing clear explanations of benefits and any
communications they receive re: claims, cost sharing
SNP 4 through 6 Training
46
SNP 6 Element A
• Documentation - SNPs must provide
reports and may include documented
processes or materials to supplement
them
– Reports:
• Evidence of Coverage (EOC) documentation
– Materials:
• Scripts or guidelines for staff who help members
with eligibility, benefits and claims for both
Medicare and Medicaid (Factors 1 & 2)
• Job descriptions for staff who help members with
eligibility, benefits and claims for both Medicare
and Medicaid
•
SNP 4 through 6 Training
47
SNP 6 Element A
• For all factors — SNP must provide
information to members for Medicare
AND Medicaid. The SNP cannot receive
credit for any factor where it provides the
required information for only Medicare
without a report demonstrating resources
for information on Medicaid.
SNP 4 through 6 Training
48
SNP 6 Element A
• Documentation must show:
– SNP’s materials cover the details of members’
specific benefit plans
– It gives members information on staff who
can answer questions regarding both
programs in lieu of written documents
– SNP staff can answer questions about
Medicare benefits and the state’s payment
cost-sharing as well as Medicaid eligibility
and cost-sharing for services where the
member is liable.
SNP 4 through 6 Training
49
SNP 6 Element B
Not Applicable for C-SNPs & I-SNPs
Administrative Coordination of Dual-Eligible
Benefit Packages
A dual-eligible SNP coordinates Medicare
and Medicaid benefits for its members by:
•Identifying changes in members’
Medicaid eligibility
•Coordinating adjudication of Medicare/
Medicaid claims for which it is
contractually responsible
SNP 4 through 6 Training
50
SNP 6 Element B
• SNPs must demonstrate that they monitor
instances where members are losing Medicaid
eligibility and regaining Medicaid eligibility to
receive credit for factor 1.
• Factor 2 is scored “Yes” if a SNP that is not
contractually responsible for the adjudication of
Medicaid claims submits documentation
showing that it helps members understand the
state’s adjudication of claims submitted by
providers.
SNP 4 through 6 Training
51
SNP 6 Element B
Documentation
• SNPs must provide (1) documented processes
and (2) reports OR materials
– Documented processes:
• Procedures used to determine changes in
Medicaid eligibility
• Procedures used to coordinate adjudication of
Medicare and Medicaid claims
– Materials:
• Scripts or guidelines for staff who help members
eligibility, benefits, and claims for both programs
– Reports:
• Redacted reports on Medicaid eligibility used by
organization
SNP 4 through 6 Training
52
SNP 6 Element C
Not Applicable for D-SNPs
Administrative Coordination for Chronic and
Institutional Benefit Packages
• SNP shows it coordinates Medicare/Medicaid
benefits for C-SNP& I-SNP members by:
– Using a process to identify changes in members’
Medicaid eligibility
– Informing members about maintaining Medicaid
eligibility
– Giving members information about benefits they are
eligible to receive under both programs
– Giving members access to staff who can advise them
on using both programs
SNP 4 through 6 Training
53
SNP 6 Element C
• Factors 1, 3 and 4—SNP must supply
documentation that shows it provides
information to members for Medicare
AND Medicaid. The SNP cannot receive
credit for factors 1, 3 and 4 if it provides
the required information only for
Medicare.
SNP 4 through 6 Training
54
SNP 6 Element C
• To receive credit for factor 2:
– I-SNPs’ documentation must address
changes where members gain Medicaid
eligibility;
– C-SNPs’ documentation must show that they
monitor instances where members are
gaining and losing Medicaid eligibility.
SNP 4 through 6 Training
55
SNP 6 Element C
• SNP’s materials cover the details of members’ specific
benefit plans
• SNP’s staff can answer questions about Medicare
benefits and the state’s payment cost-sharing as well as
Medicaid eligibility and cost-sharing for services where
the member is liable.
• Documentation - SNPs must provide:
– Documented processes
• Procedures used to verify changes in Medicaid
eligibility
– Reports or Materials
• Sample benefit summaries provided to members
SNP 4 through 6 Training
56
SNP 6 Element C
• C-SNPs and I-SNPs are exempt from this
element if less than 5% of the members in
their SNP population are dual eligibles as
of the start of the look-back period
(April 15, 2013).
SNP 4 through 6 Training
57
SNP 6 Element D
Applicable for all SNPs*
Service Coordination
• Organization coordinates delivery of services covered by
Medicare/Medicaid through the following:
– Helping members access network providers that
participate in both programs or accept Medicaid
patients
– Educating providers about coordinating benefits for
which members are eligible and about members’
special needs
– Helping members obtain services funded by either
program when needed
* C-SNPs and I-SNPs are exempt from this element if less
than 5% of the members in their SNP population are dual
SNP 4 through 6 Training
58
SNP 6 Element D
• Helping dual-eligible members obtain
services covered by Medicare &
Medicaid
– The SNP must require that its network
physicians do not bill dual-eligible members
for more than the copayment amount which
the state pays for individuals in that category
of Medicaid eligibility.
SNP 4 through 6 Training
59
SNP 6 Element D
For factor 1
• SNP must publish a directory that shows:
– providers that participate in both programs
or
– providers that accept Medicare for services
covered by Medicare
and
– providers that accept Medicaid for dualeligible members
SNP 4 through 6 Training
60
SNP 6 Element D
Factor 2 requires SNPs to educate network
practitioners and providers about their role
coordinating Medicare/Medicaid benefits
and members’ special needs. A SNP can:
– Alert their providers to the range of benefits
or services for which members are eligible, as
well as responsibility for cost-sharing, if any,
and their right to reimbursement
– Inform providers who is responsible for
coordinating services for both programs
SNP 4 through 6 Training
61
SNP 6 Element D
Factor 3 requires SNPs to help members
obtain services funded by either program
when assistance is needed. The SNP can:
– Show processes and materials that describe
how it helps members obtain services
covered by Medicare and Medicaid
– Submit a policy and materials it gives to
members that details how they can obtain
non-emergency transportation services for
appointments and medical procedures.
SNP 4 through 6 Training
62
SNP 6 Element D
• Documentation - SNPs must provide:
– Documented processes; AND
•Policies and procedures for arranging
services for members
– Reports or Materials
•Reports detailing how members were
assisted in obtaining services from
Medicaid when needed.
•Materials such as the provider directory or
provider manuals.
SNP 4 through 6 Training
63
SNP 6 Element E
Applicable for all SNPs*
Network Adequacy Assessment
• Organization assesses the adequacy of the
network for member access to practitioners and
provider by:
- Establishing standards of the number and geographic
distribution of each type of practitioner and provider
- Conducting an annual analysis of performance against
said standards
* Element is NA for C-SNPs and I-SNPs w/less than 5% dual
eligible members and D-SNPs with no enrollment at the
start of the look-back period (April 15, 2013).
SNP 4 through 6 Training
64
SNP 6 Element E
• The SNP must provide documented
process for factors 1 and 2 and reports for
factors 3 and 4.
• The SNP’s documentation must include
the geographic and numeric standards
for practitioners and providers and a
description of its methodology used to
perform the analysis.
SNP 4 through 6 Training
65
SNP 6 Element E
• The SNP’s analysis must include a network
access indicator (ratio of member to practitioner
availability based a number of miles/minutes). A
plan that uses:
1) Access data (appointment availability)
2) Data on members’ cultural or linguistic needs
or
3) Satisfaction data (surveys, complaints and
appeals)
must supplement its assessment with another
network access indicator
SNP 4 through 6 Training
66
SNP 6 Element E
• Organization must determine adequate
access for members for the following types
of providers
– Primary care practitioners (e.g., general
practitioners, internal medicine specialists – but
break out of data by PCP type is not required)
– High volume specialists (e.g., cardiologists,
neurologists, gynecologists, psychiatrists)
– Providers (e.g., hospitals, skilled nursing facilities)
SNP 4 through 6 Training
67
SNP 6 Element E
• GEO Access analysis for a SNP’s Medicare
practitioner network only is insufficient to meet
this element. The GEO Access or other analysis
must include practitioners and providers that
accept coverage for services paid for by
Medicare and Medicaid.
• GEO Access maps must be accompanied by
an assessment of quantitative data
• If the plan can show all of its providers accept
Medicaid and Medicare then GEO Access or
other access reports are sufficient
SNP 4 through 6 Training
68
SNP 6 Element E
• Methodology must include: direct measurement
of results against standards, info about sampling
(if used) and analysis of the causes of any
deficiencies
• Factors 3 and 4 require SNP to show data
collected/analysis performed after 10/15/12
• Analyses must be SNP-specific; organizations that
perform an aggregate analysis of multiple benefit
plans must break out the data for each individual
plan.
SNP 4 through 6 Training
69
SNP 6 Element E
• SNPs must provide the following
documentation:
– Documented processes; AND
• P&Ps for assessing network adequacy
– Reports
• Reports on accessibility of Medicare and
Medicaid practitioners and providers
• Reports on access indicators such as percentage
of in-network and out-of-network use; rate of ED
use compared to norms in area; or member
surveys of satisfaction with access
SNP 4 through 6 Training
70
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.
SNP 4 through 6 Training
71
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
SNP 4 through 6 Training
72
Questions?
SNP 4 through 6 Training
73
Additional Resources
• NCQA SNP Webpage:
http://www.ncqa.org/snp
– FAQs
•Training descriptions & schedule
•Final S&P measures
• NCQA Policy Clarification Support (PCS)
http://ncqa.force.com/pcs/login
SNP 4 through 6 Training
74
Contacts
Brett Kay
Assistant Vice President, SNP Assessment
202-955-1722
[email protected]
Casandra Monroe
Assistant Director, SNP Assessment
202-955-5136
[email protected]
Sandra Jones
Assistant Director, SNP Assessment
202-955-5189
[email protected]
SNP 4 through 6 Training
75
Contacts
Anthony Davis
Accreditation Manager, SNP Assessment
202 –955-1713
[email protected]
Priyanka Oberoi
Accreditation Manager, SNP Assessment
202-955-5130
[email protected]
Nidhi Dalwadi
Accreditation Manager, SNP Assessment
202-955-3585
[email protected]
SNP 4 through 6 Training
76
Contacts
Ling Chen
Accreditation Manager, SNP Assessment
202-955-3548
[email protected]
Delia Ponce
Coordinator, SNP Assessment
202-955-1742
[email protected]
SNP 4 through 6 Training
77

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