Transcript QI 7: Complex Case Management (HPA Only)

SNP Training – Topic 3:
Structure & Process Measures 1 through 3
March 12, 19, 25 and April 23, 2009
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.
SNP Training #3: SNP Structure & Process Measures 1 thru 3
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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
SNP Training #3: SNP Structure & Process Measures 1 thru 3
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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
– 1st year—rapid turnaround, adapted existing
NCQA measures and processes from
voluntary Accreditation programs
– 2nd year—focus on SNP-specific measures
– 3rd year—Refine measures; identify new SNPspecific measures, where appropriate
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Three-Year Strategy
Phase 1 - FY 2008
SNPs Effective as of
January 2007
Phase 2 - FY 2009
SNPs Effective as of
January 2008
HEDIS 2009
(15 measures)
HEDIS 2008
(13 measures)
•Addition of two new
measures: Care for Older
Adults; Medication
Reconciliation PostDischarge
Structure & Process
Measures
Structure & Process
Measures
• SNP 1: Complex Case
Management
• SNP 2: Improving
Member Satisfaction
• SNP 3: Clinical Quality
Improvements
• SNP1 – 3
• SNP 4: Care Transitions
• SNP 5: Institutional SNP
Relationship with Facility
• SNP6: Coordination of
Medicare & Medicaid
Phase 3 - FY 2010
SNPs Effective as of January
2008
HEDIS 2010
• Measure development:
–Potentially Avoidable
Hospitalizations
–Inpatient Readmissions
–MDS measures (I-SNPs)
–Disease-specific measures (CSNPs)
Structure & Process
Measures
•Refinement of existing S&P
measures, includes the
potential development of
new elements
•Potential development of new
measures
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Who Reports
• HEDIS measures
– All SNP plan benefit packages with 30+
members as of February 2008 Comprehensive
Report (CMS website)
• S&P measures
– All SNP plan benefit packages
– Plans with no enrollment exempt from certain
elements
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What to Report
• S&P measures
• Cohort I—All SNPs operational as of
January 1, 2007 and renewed in 2009.
– S&P measures 4-7 (SNP 2:C & 3:B)
• Cohort II—All SNPs operational as of
January 1, 2008 and renewed in 2009
– All S&P measures (SNP 1-6)
• Do not report SNP 7 (SNP 2:C & 3:B)
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Project Time Line – Phase II
• March 4 - Release final S&P measures
• March 30 - Release ISS Data Collection
Tool
– S & P Measures
• April - Release IDSS Data Collection Tool
– HEDIS Measures
• June 30 - HEDIS submissions and S&P
measures submissions due to NCQA
• October 30 - NCQA delivers SNP
Assessment Report to CMS
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SNP Structure and Process Measures
Brett Kay, Director, SNP Assessment
Casandra Monroe, Assistant Director, SNP Assessment
SNP Assessment Process
• Phased Approach
– Defining and assessing desirable structural
characteristics
– Assessing processes
– Assessing outcomes
• Two main components
– HEDIS Measures-focus on clinical
performance
– Structure & Process measures-focus on
structural characteristics and systems
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S&P Measures
• Three Measures; adapted from existing
accreditation standards
– SNP 1: Complex Case Management
• Elements A-G
– SNP 2: Improving Member Satisfaction
• Elements A, B
– SNP 3: Clinical Quality Improvements
• Element A
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Components of the S&P Measures
• Standard statement: a statement about
acceptable performance or results
• Intent statement: A sentence that describes the
importance of the S&P measure
• Element: The component of the measure that is
scored and provides details about performance
expectations. NCQA evaluates each element
within the measure to determine the degree to
which the SNP has met the requirements within
the S&P measure.
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Components of an S&P Measure
• Factor: An item within an element that is scored
(e.g., an element may require an organization
to demonstrate that a specific document
includes 4 items. Each item is a factor).
• Scoring: The level of performance the
organization must demonstrate to receive a
specific percentage on each element (100%,
80%, 50%, 20%, 0%)
• Data source: Types of documentation or
evidence that the organization uses to
demonstrate performance on an element.
NCQA defines 4 types of data sources:
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Data Source Types
• Documented Processes: Policies and procedures, process flow
charts, protocols and other mechanisms that describe an actual
process used by the organization
• Reports: Aggregated sources of evidence of action or compliance
with an element, including management reports; key indicator
reports; summary reports of analysis; system output giving
information; minutes; and other documentation of actions that the
organization has taken
• Materials: Prepared materials or content that the organization
provides to its members and practitioners, including written
communication, Web sites, scripts, brochures, review and clinical
guidelines
• Records or Files: Actual records or files, such as denial, appeal or
credentialing flies that show direct evidence of action or
compliance with an element---NCQA does not require file review
for phase two.
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Components of an S&P Measure
• Scope of Review: The extent of the
organization’s services evaluated during an
NCQA survey.
• Look-back period: The period of time for which
NCQA evaluates an organization’s
documentation to assess performance against
an element
• Explanation: Guidance for demonstrating
performance against the element
• Example: Descriptive information illustrating
performance against an element’s
requirements. Examples are for guidance and
are not intended to be all-inclusive
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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 & who
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 culling 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
Note: NCQA looking to collect information on
eligibility criteria used by plans for CM and data
on % of members enrolled in CM.
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SNP 1: Element A FAQs
• What type of information is NCQA looking for?
– Documented processes or reports that demonstrate
the SNP is using various data sources to identify
eligible members for CM
• What if a plan automatically enrolls all members
in CM?
– Plans that auto-enroll and maintain all members in
CM can provide evidence of this and receive 100%
for this element
• What if CCM is part of larger DM program?
– SNPs must have a CCM program. This program may
be part of a broader DM program, but the SNP must
demonstrate that it meets the requirements for CCM.
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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:
• Feed information from these data sources into to a
predictive modeling system
• Describe the member identification process flow and
include resources case managers use such as:
discharge reports; reports showing multiple admissions;
hospital history; reports on past and present treatment;
lab reports; reports from ancillary and/or behavioral
health providers; information on the member’s prognosis;
cost and utilization data; catastrophic pharmacy claims;
disability claims; and aggregate claims exceeding
certain thresholds.
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SNP 1: Element B
•
Access to Case Management: Plan is open to 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 (must specify what these are)
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SNP 1: Element B FAQs
• What type of information is NCQA looking for?
– Documented processes, reports or materials that
demonstrate the SNP allows referrals from multiple
sources
• Does a SNP have to enroll every member
referred for CM?
– No. Plans do not have to enroll every member referral,
but must consider them
• Health information line referral is not required for
Medicare, do the SNPs have to have this?
– This factor may be scored “NA,” but if a SNP has an
HIL, it must accept referrals
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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 for: members need for long-term
monitoring, interventions and support
• A flowchart detailing the steps of the case management
process and persons used as referral resources within it
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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 FAQs
• What type of guidelines should be used for
Factor 1?
– Any evidence-based guidelines are acceptable.
They must provide documentation of clinical
evidence used to develop the CM system.
– Scripts or other prompts that have an evidence base
satisfy this factor
• What about frail members or those where there
are not available or appropriate guidelines?
– For frail members, plans are not required to use
guidelines that may not be appropriate
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SNP 1: Element C
• Documentation for Factor 1 may include:
– Online scripts and checklists that allow case managers to obtain
information on interventions in evidence-based care plan by
physician, any care gaps or mitigating circumstances and
assess the member’s compliance with the care plan
– Screen shots supplemented with policies or descriptions that
specify how the case manager performs the assessment
activities
– Flow charts that include descriptions of assessment process
activities and the clinical evidence used in the process
• Documentation for Factors 2 and 3 must
include:
– Screen shots from electronic case management systems that
capture the date, time, user ID, action by the case manager
along with reminders and follow-up due dates; policies or usage
instructions accompany these screen shots
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SNP 1: Element D
• Frequency of Member Identification
– Systematically identify members
– At least monthly
• given the dynamic nature of clinical data, an
organization that uses these data with greater
frequency has the greatest opportunity to identify
members who may benefit most from CM programs
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SNP 1: Element D FAQs
• What if a plan automatically enrolls all members
in CM?
– Plans that auto-enroll and maintain all members in
CM can receive 100% for this element
(if they provide appropriate documentation)
--also applies to SNP 1A, 1B and 1E Factor 2
• What type of information is NCQA looking for?
– Documented processes or reports that demonstrate
the frequency with which SNPs systematically
identify eligible members for CM
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SNP 1: Element E
•
Providing Members With Information
Does the SNP 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
• What type of data sources is NCQA looking for?
– To demonstrate performance on this element, the
SNP must provide:
• Documented processes that describe the process for
notifying members; and
• Materials provided to members
• In some states, SNPs are required to provide CM
to all members, so “opt out” should not apply
– Factor 3 is “NA” if the organization is required by
states or others to provide case management to all
members
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SNP 1: Element F
•
Case Management Process
–
Member’s right to decline
participation or disenroll
–
–
–
–
–
–
Health status
Clinical history and meds
Activities of daily living
Mental health status and cognitive function
Life planning activities
Cultural and linguistic needs, preferences or
limitations
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SNP 1: Element F (cont. …)
•
Case Management Process Requires
–
–
–
–
–
–
–
Caregiver resources
Available benefits
Case management plan with long- and short-term
goals
Barriers
Follow-up schedule
Self-management plan (needs to
be documented)
Assessing progress
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SNP 1: Element F FAQs
• Can Plans use screen shots from a
computerized questionnaire or case
management system to show compliance with
this element?
– Yes, provided the screen shots display the fields with
the relevant questions related to the factors
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SNP 1: Element F Examples
Evidence that addresses requirements in each of the
fourteen factors may consist of:
• Policies and procedures which delineate the case
manager’s actions and documentation requirements
during the initial assessment, care plan implementation
and follow-up activities. These policies must be
supplemented with questionnaires, or call scripts the call
managers uses for care plan implementation, evaluation
and follow-up activities.
• Screen shots supplemented by instructions or policies and
documentation guidelines the case manager uses during
initial assessment, care plan implementation, evaluation
and follow-up activities.
• Printer friendly versions from an electronic case
management system that detail timing, status, results of
initial assessment, care plan implementation, evaluation
and follow-up activities the case manager performs.
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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 FAQs
• What type of information is NCQA looking
for?
– To demonstrate performance on this element,
the organization must provide:
• Documented processes that describe its process
for notifying practitioners; and
• Materials provided to practitioners
• Examples of materials include:
– Provider manuals
– Training brochures
– information on Organization’s Website
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SNP 2: Improving Member Satisfaction
SNP 2: Element A
•
Assessment of Member Satisfaction
–
–
–
Identify the appropriate population
Draw appropriate samples from the affected
population, if a sample is used
Collect valid data
*Plans with no enrollment as of the start of the lookback period are exempt from this element
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SNP 2: Element A FAQs
• Does the member satisfaction apply only to the
SNP’s case management program?
– SNPs must assess member satisfaction across its
entire operations, not just its CM program.
• Can SNPs use self-reported data from members,
such as member satisfaction with practitioner
availability or other existing surveys?
– SNPs may use self-reported data to satisfy this
element.
– SNPs can use CAHPS data they have analyzed to
satisfy this element in place of analyzing complaints
and appeals
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SNP 2: Element A FAQs
• If we do not pull a sample and analyze
member satisfaction data for our entire
SNP population will NCQA score Factor 2
NA?
– NCQA scores Factor 2 “Yes” when an
organization analyzes member satisfaction
data for its entire SNP population
• How recent must the data be for this
element?
– Data must be collected no more than 12
months prior to the look back period
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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 no enrollment as of the start of the lookback period are exempt from this element
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SNP 2: Element B FAQs
• What if no opportunities for improvement are
identified?
– If no opportunities are identified in the SNP’s analysis,
and NCQA surveyors agree with this conclusion, the
element is scored “NA.”
• Do SNPs have to show improvement based on
the opportunities identified?
– Plans undergoing the SNP Evaluation for the first time
in 2009 are not required to demonstrate they have
taken action on the identified opportunities
– Plans that completed the SNP Evaluation in 2008 must
provide evidence of actions taken and a plan to
evaluate its actions
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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
•
Plans must demonstrate that each of the 3 clinical issues is
relevant to its membership.
*Plans with no enrollment as of the start of the lookback period are exempt from this element
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SNP 3: Element A FAQs
• Can a SNP use HEDIS measures to identify
relevant clinical improvements?
– SNPs may use HEDIS measures to satisfy this element
• Do SNPs have to show actual clinical
improvements for this phase?
– Plans undergoing the SNP Evaluation for the first time
in 2009 are not required to identify opportunities or
demonstrate they have taken action to show
improvement
– Plans that completed the SNP Evaluation in 2008 must
demonstrate they identified opportunities and
decided which ones to pursue.
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SNP 3: Element A FAQs
• Can a SNP submit service-oriented
performance measures and meet SNP
3A?
– No, measures for this element must involve
improvements in the quality of clinical care
• Should a SNP use a particular format for its
documentation?
– The ISS Survey tool contains a supplemental
worksheet plans can use to demonstrate
performance
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General FAQs
• Could you clarify the look-back period and
whether a SNP must develop or review all of its
documentation within that this timeframe?
– The look-back period is the three-month period prior
to survey submission—March 31, 2009 to June 30,
2009. 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.
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General FAQs
• 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
documenting their performance. In addition you
should discuss the details of this documentation with
a member of the SNP Team.
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Additional Resources
Additional Resources
• NCQA SNP Web page www.ncqa.org/snp.aspx
– FAQs (HEDIS)
– Training descriptions & schedule
– 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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Policy Clarification Support (PCS)
• PCS Web address
http://app04.ncqa.org/pcs/web/asp/TIL_ClientLogin.asp
• Link for SNP Web page
www.ncqa.org/snp.aspx
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Policy Clarification Support (PCS)
• Under “Standard Categories/HEDIS
Domain,” select one of the following
options:
– SNP – General Reporting Guidance
– SNP – HEDIS
– SNP – Structure & Process Measures
• Menu options under “Standard/Measures”
– If “SNP – General Reporting Guidance” was
selected:
• Not Applicable
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Policy Clarification Support (PCS)
Menu options under “Standard/Measures”
• If “SNP – HEDIS” was selected:
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(COL) Colorectal Cancer Screening
(GSO) Glaucoma Screening in Older Adults
(COA) Care for Older Adults
(SPR) Use of Spirometry Testing in the Assessment & Diagnosis of COPD
(PCE) Pharmacotherapy Management of COPD Exacerbation
(CBP) Controlling High Blood Pressure
(PBH) Persistence of Beta Blocker Treatment After a Heart Attack
(OMW) Osteoporosis Management in Older Women
(AMM) Antidepressant Medication Management
(FUH) Follow-Up After Hospitalization for Mental Illness
(MPM) Annual Monitoring for Patients on Persistent Medications
(DDE) Potentially Harmful Drug-Disease Interactions
(DAE) Use of High Risk Medication in the Elderly
(MRP) Medication Reconciliation Post-Discharge
(BCR) Board Certification
(HOS) Medicare Health Outcomes Survey
Other
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Policy Clarification Support (PCS)
Menu options under “Standard/Measures”
• If “SNP – Structure & Process” was selected:
–
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–
–
–
–
SNP 1: Complex Case Management
SNP 2: Improving Member Satisfaction
SNP 3: Clinical Quality Improvements
SNP 4: Care Transitions
SNP 5: Institutional Relationship with Facilities
SNP 6: Coordination of Medicare and Medicaid
Services
– Other
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Additional SNP Trainings
• SNP Subset of HEDIS Measures
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March 3rd
March 11th
March 16th
March 26th
April 1st
11:30 – 1:00
11:30 – 1:00
1:00 - 2:30
1:00 - 2:30
12:30 - 2:00
• Structure and Process Measures (S&P 1-3)
–
–
–
–
March 12th 1:00 – 2:30
March 19th 1:00 - 2:30
March 25th 12:30 - 2:00
April 23rd 2:00 – 3:30
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Additional SNP Seminars
• Structure and Process Measures (S&P 4-6)
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March 17th 2:00 - 3:30
March 24th 2:00 - 3:30
March 31st 2:00 - 3:30
April 2nd 12:30 – 2:00
April 7th
2:00 - 3:30
April 15th 1:00 – 2:30
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April 8th 1:00 – 2:30
April 14th 1:00 - 2:30
April 17th 1:00 – 2:30
April 21st 1:00 - 2:30
April 28th 1:00 – 2:30
May 7th 1:00 – 2:30
• Interactive Survey System (ISS)
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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]
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Questions?
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