Transcript QI 7: Complex Case Management (HPA Only)

SNP 1 through 3 Training
July 9, 11 and 16, 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 Training – 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 – 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
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 Training – SNP Structure & Process Measures 1 thru 3
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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 Training – SNP Structure & Process Measures 1 thru 3
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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 Training – SNP Structure & Process Measures 1 thru 3
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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 Training – SNP Structure & Process Measures 1 thru 3
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Structure and Process Measures
SNP 1: Care Management and
Coordination
SNP 1- Care Mgmt. and Coordination
Changes since 2012
• Replaced elements of Complex Case
Management with new ones for Care
Management that assess whether SNPs
have appropriate programs to coordinate
services and help all members access
needed resources
• Better align with CMS MOC requirements
for assessment and care plans
SNP Training – SNP Structure & Process Measures 1 thru 3
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SNP 1- Care Mgmt. and Coordination
Changes continued
Care Mgmt. and Coordination consists of Elements
A:
B:
C:
D:
E:
F:
G:
Care Management Program Description
Population Description
Care Management Process
Individualized Care Plan
Satisfaction with Care Management
Analyzing Effectiveness/Identifying Opportunities
Implementing Interventions and Follow-up
Evaluation
SNP Training – SNP Structure & Process Measures 1 thru 3
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SNP 1- Care Mgmt. and Coordination
Definition - Care management is a set of
activities designed to assist patients and
their support systems in managing medical
conditions and related psychosocial
problems more effectively, with the aims of
improving patients’ functional health status,
enhancing coordination of care,
eliminating duplication of services and
reducing the need for expensive medical
services.
SNP Training – SNP Structure & Process Measures 1 thru 3
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SNP 1- Care Mgmt. and Coordination
Element A - Program Description
The SNP has a description for its Care Mgmt.
program that includes:
1. Evidence used to develop the program
2. Criteria for identifying members who are
eligible for the program
3. Services offered to eligible members
4. Defined program goals
Data source: documented process
SNP Training – SNP Structure & Process Measures 1 thru 3
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SNP 1- Care Mgmt. and Coordination
• Care Mgmt. program focuses on
member-specific activities and the
coordination of services; it involves:
– Comprehensive assessment of member’s
condition
– Determining benefits/resources
– Developing and implementing a care plan
that includes performance goals, monitoring
and follow-up
SNP Training – SNP Structure & Process Measures 1 thru 3
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SNP 1- Care Mgmt. and Coordination
A SNP must have a Care Mgmt. Program
• Based on the subpopulations within its
membership SNPs may have the following
within a larger Care Mgmt. Program:
– Complex case mgmt
– Transitional case mgmt
– High-risk/high utilization programs
– Hospital case mgmt
SNP Training – SNP Structure & Process Measures 1 thru 3
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SNP 1- Care Mgmt. and Coordination
• Factor 1 requires the SNP to describe the
evidence it used to develop the program.
– E.g., clinical practice guidelines; scientific
evidence from clinical or technical literature or
government research; or literature reviews for
nonclinical aspects of the program like dealing
with or promoting behavioral change.
• Program description must also detail the
criteria SNP uses to identify eligible
members for factor 2
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SNP 1- Care Mgmt. and Coordination
• SNP’s description includes the services it
provides to members.
• Org that stratifies members based on risk
or level of need must include eligibility
criteria, services to be provided and goals
for each tier.
• Program description also needs to include
goals that reflect specific objectives and
targets.
SNP Training – SNP Structure & Process Measures 1 thru 3
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SNP 1- Care Mgmt. and Coordination
Element B – Population Assessment
• Annually SNP must:
1. Assess the characteristics and needs of
member population and pertinent
subpopulations
2. Review and update Care Mgmt. processes to
address member needs
3. Review and update Care Mgmt. resources to
address member needs
Data source: Documented process
SNP Training – SNP Structure & Process Measures 1 thru 3
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SNP 1- Care Mgmt. and Coordination
• Population assessment includes SNP’s
covered population not just members in
specific programs like CCM
• Documentation must show how:
– SNP considers specific member characteristics
when designing and revising program e.g.,
• Medicaid eligibility categories
• Nature and extent of carved out benefits
• Type of SNP
• Race/ethnicity and language preferences
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SNP 1- Care Mgmt. and Coordination
• Population assessment procedures also
need to include consideration of
program characteristics and resources
e.g., staffing ratios, clinical qualifications,
job training, external resources and
cultural competency
• SNP’s documentation needs to be dated
after 10/15/12
SNP Training – SNP Structure & Process Measures 1 thru 3
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SNP 1- Care Mgmt. and Coordination
Element C - Care Mgmt. Assessment Process
• Includes all info for SNP to assess members’
needs and develop interventions for them
• A SNP’s documentation must address all 8
factors
• It may submit assessment tools or
screenshots as evidence, if these
documents demonstrate the system has all
required functionality
Data sources: Documented process and reports or materials
SNP Training – SNP Structure & Process Measures 1 thru 3
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SNP 1- Care Mgmt. and Coordination
SNP’s evidence must include:
• Documentation of clinical history and meds
– e.g., disease onset, inpatient stays, treatment
history
• Initial assessment of:
– health status & comorbidities
– activities of daily living
– mental health status and cognitive function
• both aspects are required
SNP Training – SNP Structure & Process Measures 1 thru 3
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SNP 1- Care Mgmt. and Coordination
• Evaluation of:
– cultural and linguistic needs
•review of language needs meets factor 5
– visual & hearing needs, preferences/limitations
– caregiver resources
• e.g., family involvement in decision making
– available benefits
• covered by SNP, carved out for supplemental
services such as community behavioral health or
national and community resources
SNP Training – SNP Structure & Process Measures 1 thru 3
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SNP 1- Care Mgmt. and Coordination
Element D - Individualized Care Plan
• SNP uses info from assessment e.g., HRAs and
other sources to develop a comprehensive care
plan
• Care plan includes info on actions or
interventions and their duration a SNP’s
Interdisciplinary Care Team (ICT) takes to
address members’ medical, BH, functional and
support needs.
Data sources: Documented process and reports or materials
SNP Training – SNP Structure & Process Measures 1 thru 3
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SNP 1- Care Mgmt. and Coordination
• A SNP’s documentation shows that the ICT
develops a care plan for each member that
includes:
– prioritized goals that reflect member’s or
caregiver’s preferences and involvement
– self-management plan
– schedule for follow-up/identify barriers
– process to assess member progress
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SNP 1- Care Mgmt. and Coordination
• Based on the member’s specific needs
the care plan also identifies:
– resources to be utilized and appropriate level
of care
• CMs as members of the ICT often facilitate referrals
to other providers as part of member’s benefits
– planning for coordination of care including
transitions and transfers
• identifying how and when ICTs follow up with a
member after referral to a health resource
– collaborative approaches to be used
SNP Training – SNP Structure & Process Measures 1 thru 3
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SNP 1- Care Mgmt. and Coordination
Element E - Satisfaction with Care Mgmt
Intent is for SNP to obtain feedback on its Care
Mgmt. program from a broad sample of
members, not just those that contacted it
• SNP must submit a report showing it performed
an evaluation of satisfaction by:
1) Obtaining feedback from members
2) Analyzing member complaints and inquiries
Data source: Reports
SNP Training – SNP Structure & Process Measures 1 thru 3
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SNP 1- Care Mgmt. and Coordination
Factors 1 and 2 require SNPs to use:
• focus groups or satisfaction surveys that are
specific to Care Mgmt program
– e.g., assess satisfaction with--program staff,
the usefulness of info received, member’s
ability to adhere to recommendations.
• analysis of complaint and inquiry data after
10/15/12 to identify patterns or trends
– quantitative and qualitative
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SNP 1- Care Mgmt. and Coordination
• Factors 1 and 2 focus on satisfaction with
the Care Mgmt. Program not satisfaction
with the SNP’s overall operations
• Reports with data obtained from CAHPS or
general surveys will not meet the intent
• Results from satisfaction surveys
administered across multiple SNPs must
be stratified at individual plan level for
analysis
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SNP 1- Care Mgmt. and Coordination
• Factor 2 is NA if SNP provides evidence
(e.g., tracking mechanism) showing it did
not receive any Care Mgmt. complaints
and inquiries after 10/15/12
• Factors 1 and 2 are NA for SNPs that did
not have any members at the start of the
look-back period, per the CMS April 2013
Comprehensive Report.
SNP Training – SNP Structure & Process Measures 1 thru 3
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SNP 1- Care Mgmt. and Coordination
Element F - Analyzing Effectiveness/
Identifying Opportunities
• The SNP measures the effectiveness of its Care
Mgmt. program using three measures. For each
measure, it:
1)
2)
3)
4)
5)
6)
Identifies a relevant process or outcome
Uses valid methods that provide quantitative results
Sets a performance goal
Clearly identifies measure specifications
Analyzes results
Identifies opportunities for improvement, if applicable
Data source: Reports
SNP Training – SNP Structure & Process Measures 1 thru 3
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SNP 1- Care Mgmt. and Coordination
SNP’s report must contain appropriate measures
likely to have significant and demonstrable
bearing on all or a subset of Care Mgmt. members
– Outcomes based
– Relevant to target population
– Valid methodology
• Contains info on sampling (if used) and sample size
calculation
• Measurement periods reflect the effects of
seasonality
– Denominator specific to Care Mgmt. population
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SNP 1- Care Mgmt. and Coordination
Report shows appropriate analysis – goes beyond
simple reporting or data display
– Comparison to goal or benchmark
• Measure must not have exceeded goal from outset
– Quantitative and qualitative
– Opportunities for improvement
• SNP can use 3 patient experience measures
• e.g., improved quality of life, pain
management and health status
• May only use 1 satisfaction measure with Care
Mgmt. program operations
SNP Training – SNP Structure & Process Measures 1 thru 3
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SNP 1- Care Mgmt. and Coordination
• Scoring is based on an average for all 3
measures
• Analysis of measures must be SNPspecific. Org can present aggregate
analysis if it breaks out data and results for
individual SNPs
• SNP must have performed analyses of
measures after 10/15/12
• SNPs that submit Care Mgmt. worksheets
also need to provide actual reports
SNP Training – SNP Structure & Process Measures 1 thru 3
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SNP 1- Care Mgmt. and Coordination
• Factor 6 is NA if a plan’s documentation
confirms it does not have any
opportunities for improvement
• Factors 1 thru 6 are NA for SNPs that did
not have any members at the start of the
look-back period, per the CMS April 2013
Comprehensive Report.
SNP Training – SNP Structure & Process Measures 1 thru 3
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SNP 1- Care Mgmt. and Coordination
• Examples of measures
– HEDIS measures of effectiveness for chronic
conditions
• e.g., controlling high blood pressure, persistence
of beta blocker treatment after a heart attack
– SF-36 or SF-12 results
– Use of service measures for which consensus
indicates improvement – e.g., reduced ED
visits
– Readmission rates
– Ambulatory-care sensitive admissions
SNP Training – SNP Structure & Process Measures 1 thru 3
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SNP 1- Care Mgmt. and Coordination
Element G - Implementing Interventions and
Follow-up Evaluation
• Based on the results of its measurement and
analysis of Care Mgmt. effectiveness, the
organization:
1) Implements at least one intervention for
each of the three opportunities identified in
Element F to improve performance
2) Develops a plan for evaluation of the
intervention and re-measurement
Data source: Documented process and Reports
SNP Training – SNP Structure & Process Measures 1 thru 3
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SNP 1- Care Mgmt. and Coordination
• Scoring is based on an average for all 3
measures
• Interventions must have been
implemented after 10/15/12
• A SNP’s documentation needs to show
that it developed a plan to evaluate the
effectiveness of its interventions; this
evaluation includes re-measurement
using methods consistent with initial
measurement.
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SNP 1- Care Mgmt. and Coordination
• Factor 1 may be NA if no opportunities
• Factor 2, re-measurement, must be
completed whether there are
opportunities or not.
• SNPs that did not have any members at
the start of the look-back period, per the
CMS April 2013 Comprehensive Report
receive an NA for factors 1 and 2.
SNP Training – SNP Structure & Process Measures 1 thru 3
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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.
SNP Training – SNP Structure & Process Measures 1 thru 3
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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 Training – SNP Structure & Process Measures 1 thru 3
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Questions?
SNP Training – SNP Structure & Process Measures 1 thru 3
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SNP 2: Improving Member Satisfaction
Summary of Changes for 2013
• SNP 2 Elements A and B
– Now applicable to both initial and returning
SNPs
• SNP 2 Element C
– Added new example for factor 2 that
emphasizes continuing the intervention and
then re-measuring if an organization does not
meet its initial goal
SNP Training – SNP Structure & Process Measures 1 thru 3
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SNP 2: Overview
• Who reports?
– Initial and returning SNPs are responsible for
reporting all of SNP 2. This includes Elements
A, B and C
– SNPs that did not have any members at the
start of the look-back period will receive a
score of NA for the measure
• Per the CMS April 2013 SNP Comprehensive Report
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SNP 2 Element A
Assessment of Member Satisfaction
• a SNP must supply BOTH a documented process
and a report explaining how it performed the
assessment and an analysis of member
satisfaction data that shows it:
– identified the appropriate population
– selected appropriate samples from the affected
population, (if used)
– conducted an quantitative and qualitative
analysis annually
• The SNP will receive credit for factor 2 if it collects
data for its entire population
SNP Training – SNP Structure & Process Measures 1 thru 3
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SNP 2 Element A
• A SNP’s complaint and appeal data must relate to at
least the four major categories
– Quality of Care
– Access
– Attitude and Service
– Billing and Financial
• It must submit a report that shows the quantitative and
qualitative analyses were performed after 10/1/12.
• Complaint, grievance and appeal data or satisfaction
survey data collected more than 12 months prior to the
start of the look-back period--(4/15/12) will not meet
the intent
SNP Training – SNP Structure & Process Measures 1 thru 3
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SNP 2 Element A
• All SNP complaint/appeal data must be at
the PBP level. The SNP should receive a
score of:
– 50% for data only identified as “Medicare”
– 0% if data source is not specified at all
• SNPs must perform their own analysis of
CAHPS results, not just attach a vendor’s
report to meet the intent of Element A.
SNP Training – SNP Structure & Process Measures 1 thru 3
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SNP 2 Element A
• If the SNP has no complaints, appeals or
grievances, it must still show a table,
spreadsheet or other documentation that
demonstrates it collected appropriate
data for an analysis and found no
complaints or appeals for its members
SNP Training – SNP Structure & Process Measures 1 thru 3
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SNP 2 Element A
• The analysis must be SNP-specific; plans
must break out the data at the PBP level
for an aggregate analysis of complaints
and appeals across multiple benefit plans
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SNP 2 Element B
Opportunities for Improvement
• Element B requires a SNP to show:
– How it identifies opportunities for improvement of
member satisfaction (documented processes)
– At least 2 opportunities for improvements based on its
data and analysis for SNP 2A (reports)
– It identified opportunities after 10/1/12.
• Analysis should indicate reasons for opportunities
identified
– May be lesser priorities
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SNP 2 Element B
• Element B is NA if:
– a SNP’s analysis does not result in the
identification of one or more opportunities for
improvement.
• Reasons for no improvement opportunities
may include:
– no or very low enrollment
– no trendable data available
– very low number of complaints/appeals
SNP Training – SNP Structure & Process Measures 1 thru 3
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SNP 2 Element C
Improving Satisfaction
• Element C requires a SNP to show that it is
actively working on implementing interventions
and measuring their effectiveness.
– Plans must provide BOTH documented
processes and reports
• The interventions must relate to opportunities
identified in SNP 2B
• Do not have to show improvement on
interventions, but a SNP must show it measured
intervention effectiveness.
SNP Training – SNP Structure & Process Measures 1 thru 3
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SNP 2 Element C
• Timeframes
– Interventions must be implemented within
one year of the submission date (October 15,
2012 – October 15, 2013)
– Analysis of intervention effectiveness or
remeasurement for those that do not have
opportunities must be performed within the
look-back period (April 15, 2013 – October
15, 2013)
SNP Training – SNP Structure & Process Measures 1 thru 3
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SNP 2 Element C
• When evaluating intervention
effectiveness for factor 2 - SNPs must
perform remeasurement against an
original goal, or a targeted intermediate
measurement of specific interventions
SNP Training – SNP Structure & Process Measures 1 thru 3
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SNP 2 Element C
• If a SNP has no members as of the start of
look-back period, then this element is
“NA”.
– Per the CMS April 2013 SNP Comprehensive
Report
• Initial SNPs with no opportunities for
improvement get an “NA” for factors 1-2
• Returning SNPs with no opportunities for
improvement get an “NA” for factor 1
only
SNP Training – SNP Structure & Process Measures 1 thru 3
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Polling Question
SNP Training – SNP Structure & Process Measures 1 thru 3
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Polling Question
• True or false.
– For SNP 2 Element C, a returning SNP will
be scored “NA” for factor 2 if the
analysis of satisfaction data shows it
does not have opportunities for
improvement
SNP Training – SNP Structure & Process Measures 1 thru 3
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SNP 3: Clinical Quality Improvement
SNP 3 Element A
• Methodology has been revised to calculate
statistically significant improvement. The new
methodology better addresses the “small
numbers” issues related to low enrollments and
denominators for many of the HEDIS measures
and more accurately reflects year-to-year
improvement without penalizing plans.
• SNPs that do not have 30 members as of the
CMS February 2012 SNP Comprehensive Report
are exempt from reporting this measure and
receive a score of “NA.”
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SNP 3 Element A
• What is statistical significance?
–
–
–
–
–
–
0-59: At least a 6 percentage point change
60-74: At least a 5 percentage point change
75-84: At least a 4 percentage point change
85-92: At least a 3 percentage point change
93-96: At least a 2 percentage point change
97-99: At least a 1 percentage point change
• This applies to measures where both
higher and lower percentages are better
SNP Training – SNP Structure & Process Measures 1 thru 3
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SNP 3 Element A
• Which SNPs must demonstrate clinical
improvement?
– Only returning SNPs will be scored
– Initial SNPs and plans with <30 members (as of
Feb 2012 CMS Comp. Report) are exempt
• Plans are not required to submit anything
in ISS. NCQA will score this element
internally.
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Questions?
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