Read QI 7: Complex Case Management (HPA Only) text version

SNP Training ­ Topic 3: Structure & Process Measures 1 through 3

December 9 and 15, 2010 and January 11, 2011

Objective of S&P Measures Training

· Describe the SNP assessment project NCQA is executing on behalf of CMS · Explain the intent of the S&P Measures

· Determine what type of documentation to provide · Demonstrate how NCQA will survey the measures.

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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

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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 voluntary Accreditation programs

2009 - focus on SNP-specific measures 2010 - refine existing measures 2011 - clarified requirements in SNP 1 thru 6

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Year to Year Strategy

Phase 1 -FY 2008 SNPs Effective as of January 2007 HEDIS 2008 Measure Development · 13 existing measures Phase 2 - FY 2009 SNPs Effective as of January 2008 HEDIS 2009 Measure Development · 13 existing measures · Introduced 2 new measures

-- Care for Older Adults -- Medication Reconciliation Post-discharge Structure & Process Measures · SNP 1: Complex Case Management · SNP 2: Improving Member Satisfaction · SNP 3: Clinical Quality Improvements Structure & Process Measures · SNP 1-3 · SNP 4: Care Transitions · SNP 5: Institutional SNP Relationship with Facility · SNP 6: Coordination of Medicare & Medicaid

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Year to Year Strategy

Phase 3 - FY 2010 SNPs Effective as of January 2009 Phase 4 -FY 2011 SNPs Effective as of January 2010 HEDIS 2011 Measure Development · 15 existing measures

HEDIS 2010

Measure Development Same as 2009

In development for 2011 Plan all-cause readmissions Structure & Process Measures Refinement of existing measures: SNP 4&6 Begin work to focus on evidence of implementation

Introduced 1 new measure

-- Plan all-cause readmissions Structure & Process Measures

Clarified requirements Moved analyses to separate elements

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Who Reports

· HEDIS measures

­ All SNP plan benefit packages with 30+ members as of February 2010 Comprehensive Report (CMS website)

· S&P measures

­ All SNP plan benefit packages ­ Plans with zero enrollment are exempt for certain elements

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What to Report

S&P measures · Returning Survey -- All SNPs that were operational as of January 1, 2010 AND renewed for 2011- previously submitted.

­ All S&P measures (SNP 1 ­ 6)

· Initial Survey -- All SNPs operational as of January 1, 2010 and renewed for 2011 reporting for the first time.

­ All S&P measures (SNP 1-6)

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Project Time Line ­ Phase IV

· November 2010 through February 2011- Training for SNPs · November 22, 2010 - Release ISS Data Collection Tool for S&P Measures · February 28, 2011- S&P Measure submissions due to NCQA · April 2011 - Release IDSS Data Collection Tool for HEDIS measures · June 30, 2011 - HEDIS submissions due to NCQA · September 28, 2011 - NCQA delivers SNP Assessment Report to CMS

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Project Timeline - 2012

· Release S&P Measures-2nd Qtr 2011

· Conduct trainings/tech assistance-4th Qtr 2011 · S&P Measures due- February 28, 2012

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SNP Structure & Process Measures

S&P Measures 1-3

· Three Measures; adapted from existing accreditation standards

­ SNP 1: Complex Case Management

· Elements A-G

­ SNP 2: Improving Member Satisfaction

· Elements A · Element B · Element C Not Reported in 2010 or 2011

­ SNP 3: Clinical Quality Improvements

· Element A · Element B Not Reported in 2010 or 2011

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Data Source Types

Reports

Documented Process

Materials

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Data Source Types--Process

Documented Process

This policy applies to all ABC Health staff unless otherwise noted.

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Data Source Types

Reports

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Data Source Types

Reports

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Data Source Types

Materials

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S&P Assessment

· Plan Comment Period

­ Plans will have an opportunity to provide additional information to clarify issues from original submission materials ­ Quick turnaround: Plans will have to respond to NCQA requests for more information rapidly ­ One-time opportunity: Only chance plans have before data is finalized and sent to CMS ­ If you have questions, please contact a SNP team member immediately

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Look-Back Period

· Could you clarify the look-back period and whether a SNP must develop or review all of its documentation within this timeframe?

­ The look-back period is the three-month period prior to survey submission ­ November 28, 2010 to February 28, 2011. All documentation must be current as of the look-back period but it could have been developed before that time. ­ For evidence consisting of a policy, an organization that did not have one in place can develop and incorporate it into its operations during the look-back period. ­ For analyses, the SNP may use data from outside the look back period, but not prior to July 1, 2010.

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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.

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A Word 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

· NCQA requests that you work to attach no more than 3 documents per element

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Documentation

· NCQA encourages all SNP Contacts to plan to attend an ISS Training session where the SNP Team will review ways to organize your documentation.

Use legal line numbering! Highlight key text within document! Enter background info in explanation boxes! Insert hyperlinks for relevant sections!

Add labels and arrows!

Try using a roadmap!

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SNP 1: Complex Case Management

SNP 1: Complex Case Management

· The organization helps members with multiple or complex conditions to obtain access to care and services and coordinates their care NCQA definition: Complex Case Management The systematic coordination & assessment of care & services provided to members who have experienced a critical event or diagnosis that requires the extensive use of resources & need help navigating the system to facilitate appropriate delivery of care & services

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SNP 1: Element A

· Identifying Members for Case Management

­

­

Looking for evidence plans are mining from the applicable data sources to find members eligible for CM Data Sources

· · · · · claims or encounter data hospital discharge data pharmacy data laboratory results data collected through the UM process, if applicable

Not referrals which are assessed in Element B

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SNP 1: Element A

· Eligibility in complex case management (CCM) is broader than just one specific condition or previous enrollment in a disease-specific DM program.

· A SNP that auto-enrolls members must provide documentation demonstrating that it auto-enrolls and maintains all members in case management

· SNPs must provide documented processes and may provide reports to supplement

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SNP 1: Element A Examples

Documentation describes how the organization uses the specified data sources to determine if a member is eligible and may:

· Detail the member identification process flow and include resources case managers use such as:

-

discharge reports (showing multiple admissions)

reports from ancillary and/or behavioral health providers

-

-

reports on past and present treatment

hospital history

-

lab reports

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SNP 1: Element B

· Access to Case Management: Plan accepts referrals from other sources to consider members for CM

­ ­ ­ ­ ­ ­ ­ · Health information line referral DM program referral Discharge planner referral UM referral, if applicable Member self-referral Practitioner referral Other referrals (SNPs must specify what these are in the support text box) Not every member referred to CM has to be enrolled; however, they must be considered for case management based on the eligibility criteria.

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SNP 1: Element B Examples

Documentation may include:

· A policy for the case management referral process that identifies which persons or entities refer members for services · A description which indicates how the organization uses the data sources to confirm case management referrals are appropriate · A flowchart detailing the steps of the case management process and persons used as referral resources within it

Star Health Plan TM

This policy applies to all ABC Health staff unless wise noted.

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SNP 1: Element C

· Case Management Systems

­ ­

Conduct assessment and management

· evidence-based clinical guidelines or algorithms · scripts or protocols with EBG meet the intent

Automatic documentation of contacts

· the staff member who made contact · the date and time when the organization acted on the case or interacted with the member

­

Automated prompts for follow-up, as required by the case management plan

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SNP 1: Element C

SNPs may demonstrate system functionality by addressing the following: · Must reference evidencebased guidelines or · Display system's decision tree/algorithms · Must submit documented processes - policies and procedures - instruction manuals - flowcharts · Must provide screenshots

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SNP 1: Element C

Automatic documentation of contacts

·The staff member who made contact (a)

a

b

c

· Automated prompts ·The date and time when the for follow-up, as organization acted on the case or interacted with the member (b) required by the case management plan (c)

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SNP 1: Element D

· Frequency of Member Identification

· Systematically identify members at least monthly

- an organization that uses these data with greater frequency has the greatest opportunity to identify members · Initial HRA or other new member assessment insufficient · SNPs must provide documented processes and may provide reports to supplement

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SNP 1: Element E

· Providing Members With Information: SNPs must give members written and verbal information on:

­

­

­

How to use the services How members become eligible to participate How to opt in or opt out

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SNP 1: Element E

To demonstrate performance on this element, the SNP must provide:

·Documented processes that describe the process for notifying members; and ·Materials provided to members ·Phone scripts for in-person/phone communication

·A SNP must provide documentation to satisfy both requirements (written and in-person) for each factor or it does not receive credit for them

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SNP 1: Element E

In some states, SNPs are required to provide CM to all members, so "opt out" does not apply. Factor 3 is "NA" if the organization is required by states or others to provide case management to all members; however, a SNP must submit documentation to support its claim for "NA"

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SNP 1: Element F

· Case Management Process

Now has 15 factors

­ Informing member of the right to decline participation or disenroll ­ Documentation of clinical history and meds ­ Assessment of: · Health status and comorbidities · Activities of daily living · Mental health status and cognitive function · Life planning activities

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SNP 1: Element F

· Case Management Process continued

­ Evaluation of:

· · · · Visual & hearing needs, preferences or limitations Cultural and linguistic needs, preferences or limitations Caregiver resources and available benefits Identified barriers

Case management plan with and short-term goals Schedule for follow-up Self-management plan Process to assess member progress long

­

Development of:

· · · ·

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SNP 1: Element F Examples

Policies and Procedures

Star Health Plan TM

Process Flow Charts

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·Language review is sufficient to receive credit for factor 7 ·Actual HRA forms or screenshots of assessment systems

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SNP 1: Element G

· Informing and Educating Practitioners

­ ­ Instructions on how to use CM services How the organization works with a practitioner's patients in the program

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SNP 1: Element G Examples

· SNPs must provide documented processes and materials for each factor · A SNP that only provides 1 form of documentation does not receive credit for the factor · Examples of materials sent to providers

­ ­ ­ ­ ­ Newsletter Provider web portal Letter Brochure Provider Manual

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SNP 2: Improving Member Satisfaction

SNP 2: Element A

· Assessment of Member Satisfaction

Requires organizations to assess member satisfaction across the entire organization; data limited to specific programs (e.g. case management) does not meet intent. ­ ­ ­ Identify the appropriate population Draw appropriate samples from the affected population, if a sample is used Collect valid data

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SNP 2: Element A

· SNP's analysis of grievance/complaint and appeal data ­ Must be recent and relevant to SNP population (not collected more than 12 months prior to look-back period) ­ Must be specific to plan benefit package

­ An org with multiple SNPs can submit an aggregate analysis as long as it breaks out data and results for each SNP

· Analysis (not just a data display)

­ Documentation must include evidence of analysis of report findings to include:

I. II. III. Data collected Sampling methodology Quantitative & qualitative analysis

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SNP 2: Element A

· CAHPs results or other member satisfaction survey can

be used in lieu of grievance and appeal data

­ Providing only the SNP's CAHPS report from the vendor is not acceptable to meet all factors. ­ SNP must conduct its own analysis of the CAHPS results or use another member satisfaction survey for which it conducted an analysis.

SNP 2 : Element A is NA if the SNP has no members as of December 2010 CMS Comprehensive Report. SNP must declare the lack of membership by using the NA option

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Rate per 1,000 Members (goal < 4.5 ptm)

Quality of Care

2008 Priority #1

Materials / Benefit Clarification

Administrative

Auth/Referral

Complaint Provider Related Enrollment / Disenrollment Eligibility Verification

2008 Priority #2

Sales Grievance

Example of Analysis

Transportation

Provider Office

Inappropriate Billing

2009

0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 Access

Rx related

2008

Chart 4 SNP Member Grievance And Appeals by Category - Primary Level All Plans Annual Evaluation

SNP 2 A Factors 1-2

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Claims Appeals

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Example of Analysis Report

SNP 2A

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SNP 2: Element B

· Opportunities for Improvement

­

­

Plans must review their data and determine how best to improve

Identify opportunities * Plans with zero enrollment as of the start of the lookback period are exempt from this element

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SNP 2: Element B

· SNP 2 : Element B is NA if the SNP has no members as of the December 2010 CMS Comprehensive Report. ­ SNP must provide documentation supporting its NA claim

· SNP must analyze data and identify opportunities for improvement

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SNP 2: Element C

· SNP 2 : Element C reporting is not required in 2011

Under consideration for 2012 · The SNP is expected to: ­ implement interventions based on opportunities

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SNP 3: Clinical Quality Improvements

SNP 3: Element A

·

­

The organization measures quality of clinical care to improve that care

Organization selects 3 measures to assess performance and identify clinical improvements that are likely to have an impact on the membership

· Organizations can use HEDIS or non-HEDIS clinical measures. If the organization uses non-HEDIS clinical measures, it must demonstrate how these measures are relevant to their SNP population.

Plans with zero enrollment as of the start of the lookback period are exempt from this element

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SNP 3: Element A

· SNPs can use their required Medicare QIP or QIA programs to satisfy this measure, provided the measures are: ­ Appropriate ­ Clinical in nature and relevant ­ Specific to their plan benefit package

SNP 3 : Element A is NA if the SNP has no members as of the December 2010 CMS Comprehensive Report. NCQA will verify enrollment to confirm scoring.

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Worksheet Example

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Worksheet Example

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SNP 3: Element B

· SNP 3:Element B reporting is not required for 2011

Under consideration for 2012 · The SNP is expected to: ­ collect appropriate data ­ analyze data collected (quantitative and qualitative analysis) ­ identify goals/benchmarks and barriers to improvement ­ identify opportunities for improvement and decide which to pursue for each of three measures selected in SNP 3: Element A

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Additional Resources

Additional Resources

· NCQA SNP Web page

http://www.ncqa.org/snp

­ FAQs (HEDIS and S&P measures) ­ Training descriptions, schedule & Registration ­ S&P measures

· NCQA Policy Clarification Support (PCS)

http://app04.ncqa.org/pcs/web/asp/TIL_ClientLogin.asp

· HEDIS Audit information

http://www.ncqa.org/tabid/204/Default.aspx

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Additional SNP Trainings

· SNP Subset of HEDIS Measures

­ February 25 ~ 12 ­ 2:00 pm ­ March 2 ~ 1 ­ 3:00 pm ­ March 4 ~ 1­ 3:00 pm

· Structure and Process Measures (S&P 1-3)

­ December 9 ~ 1-3:00 pm ­ December 15 ~ 1-3:00 pm ­ January 11 ~ 1-3:00 pm ­ December 14 ~ 1-3:00 pm ­ January 12 ~ 1-3:00 pm ­ January 18 ~ 1-3:00 pm

· Structure and Process Measures (S&P 4-6)

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Additional SNP Seminars

· Interactive Survey System (ISS)

­ January 13 ~ 1-2:30 pm ­ January 31 ~ 1-2:30 pm ­ February 14 ~1-2:30 pm

­ TBD

· Interactive Data Submission System

· Open Door Forums

­ January 24 ~ 1-2:00 pm ­ February 7 ~ 1-2:00 pm ­ February 22 ~ 1-2:00 pm

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Contacts

Brett Kay Director, 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] Melanie Bujanda Romero Accreditation Manager, SNP Assessment 832-582-8717 [email protected]

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Contacts

Nidhi Dalwadi Accreditation Manager, SNP Assessment 202-955-3585 [email protected] Anthony Davis Accreditation Manager, SNP Assessment 202 ­955-1713 [email protected] Priyanka Oberoi Analyst, SNP Assessment 202-955-5130 [email protected] Christopher Dillon Coordinator, SNP Assessment 202-955-3582 [email protected]

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Questions?

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Information

QI 7: Complex Case Management (HPA Only)

63 pages

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