Model of Care Training for Simply Healthcare D-SNP, I-SNP & IE-SNP

• Established by Medicare Modernization Act of 2003 (MMA 2003)

•Congress created a new type of Medicare Advantage Plan that focuses on beneficiaries that have special needs and would benefit from focused coordination of care •The core of the SNP is to provide: - Improved Access - Coordination - Continuity of Care •Focus of SNP:

- Monitoring health status of targeted population - Identifying their needs - Improving access to quality healthcare services and benefits - Managing chronic Diseases - Avoiding inappropriate hospitalizations - Decreasing members’ medical, mental and social risksk

11 Elements: 1) SNP-Specific Target Population 2) Measurable Goals 3) Staff Structure and Care Management Roles 4) Interdisciplinary Care Team 5) Provider Network with Expertise and Use of

Clinical Practice Guidelines 6) Model of Care Training for Provider Network 7) Health Risk Assessment 8) Individualized Care Plan 9) Communication of Network 10)Care Management of the Most Vulnerable

Subpopulations 11)Performance and Health Outcome Measures

ELEMENTS OF THE MODEL OF CARE

SIMPLY COMPLETE MODEL OF CARE

Member

Family and/or Caregiver

Simply Clinical Care Manager – Telephonic

Contact

PCP

Specialists

Member

Facility (NH/ALF)

Family

MANDATORY

Simply NP/PA –Face-to-Face

Contact

PCP

Specialists

SIMPLY CARE AND SIMPLY COMFORT MODEL OF CARE

HEALTH RISK ASSESSMENT

The Health Risk Assessment (HRA) is a comprehensive questionnaire done by the Care Manager that will measure the following : • Medical Needs • Psychosocial Needs • Behavioral Needs • Cognitive Needs • Functional Needs

The HRA will identify: • Potential need for specific Disease Management Programs • Members needs that require the intervention of member services or enrollment • Potential Care Management needs based on medical or psychosocial

issues

It will stratify members into levels, Low Risk, Moderate Risk or High Risk. The risk level determines the intervention provided.

CARE PLAN The Care Plan is developed by the Care Manager to address issues the member may be facing within these areas: • medical • psychosocial • behavioral • cognitive • functional • pharmaceutical The Care Plan is formulated based on: • HRA Assessment • MD Treatment Plan • Clinical Assessment • Social Evaluation • Any findings the Clinical Care Manager may have found The Care Plan is reviewed and approved by the PCP and shared with the member

CARE MANAGER

RN/LPN/MSW that will manage the members case telephonically and assist in coordinating services. • Main Care Manager functions:

- Complete Health Risk Assessments (HRA s)

- Complete Initial Individualized Care Plan and follow up Care Plans (Plan of Care)

- Coordinate Services

- Coordinate ICT meetings

- Communicate with PCP and specialists

- Communicate with member, family and/or caregivers or legal representatives

- Care Management and Disease Management

NURSE PRACTITIONER (I-SNP AND IE-SNP ONLY)

Nurse Practitioner/Physician Assistant (NP/PA) is responsible for the care management and disease management functions of the Institutional and Institutional Equivalent SNP members. Main Care Manager functions: - Work directly with the NH facility and attending physician in the facility - Complete Health Risk Assessments (HRA s) - Complete Initial Individualized Care Plan and follow up Care Plans

(Plan of Care) - Coordinate Services - Coordinate ICT meetings - Communicate between members of the ICT team - Communicate with PCP and specialists - Communicate with member, family and/or caregivers or legal

representatives

INTERDISCIPLINARY CARE TEAM

What is the Interdisciplinary Care Team (ICT)? • It is a member centered group that discusses the Care Plan, health

status and current/possible interventions for the member.

The ICT is comprised of: • The Member • Their family/caregiver or legal representative • The Care Manager • The member’s PCP • Specialists • Ancillary healthcare providers • Chief Medical Officer (as needed) • Clinical Pharmacist (as needed) • Any other entity/persons involved in the member’s care

PROVIDER NETWORK

• PCP

• MEDICAL SPECIALIST

• HOSPITALIST

• INPATIENT ACUTE CARE FACILITIES

• SKILLED NURSING FACILITIES

• LONG TERM CARE FACILITIES

• AMBULATORY SURGICAL CENTERS

• OUTPATIENT DIAGNOSTIC FACILITIES

• OUTPATIENT PT/OT THERAPY FACILITIES

• BEHAVIORAL HEALTH SPECIALIST

• LABORATORY SERVICES

• DIALYSIS FACILITIES

• HOME HEALTH SERVICES

• HOME CLINICAL ASSESSMENT AND TREATMENT PROVIDERS

• SOCIAL WORKERS

• REGISTERED AND CLINICAL PHARMACISTS

• ALLIED HEALTH PROFESSIONAL (PT/OT/ST, NUTRITIONIST, RADIOLOGY)

• ORAL HEALTH SPECIALISTS

• WOUND CARE CENTERS

• END-OF-LIFE CARE SPECIALIST

D-SNP SPECIFIC TARGET POPULATION

Dual Eligible Special Needs Plan (D-SNP) is comprised of persons dually eligible for Medicare and Medicaid benefits and services and:

• Reside in the SHP service area

• Have Medicare Part A, Part B, and Part D

• Not be under treatment for End-Stage Renal disease (ESRD)

• Have non-zero cost share

They present a unique care coordination and access challenges because they depend on Medicaid to cover services that are not covered by Medicare such as:

- Substance Abuse

- Long Term Care (LTC) Services

I-SNP SPECIFIC TARGET POPULATION

Institutional Eligible Special Needs Plan (I-SNP) is comprised of persons who are residing in a long term care facility or are expected to reside for 90 days or longer and:

• Reside in the SHP service area

• Are Entitled to Medicare Part A, and enrolled in Part B and Part D

• Not be under treatment for End-Stage Renal disease (ESRD)

**Long term care facility is defined as either a skilled nursing facility (SNF)/NF, ICF or inpatient psychiatric facility**

IE-SNP SPECIFIC TARGET POPULATION

Institutional Equivalent Eligible Special Needs Plan (IE-SNP) is comprised of persons residing in the community (home or ALF) but have met institutional level of care based on a state-approved assessment Comprehensive Assessment and Review for Long-Term Care Services (CARES) performed by a division of the Department of Elder Affairs and:

• Reside in the SHP service area

• Are entitled to Medicare Part A and enrolled in Part B and Part D

• Not be under treatment for End-Stage Renal disease (ESRD)

PROVIDER ROLES AND RESPONSIBILITIES

• Care and coordination for the member

• Participation in ICT

• Responsive and cooperative with the Care Manager

• Referring member to medically necessary services

• Communication with the member’s family or legal representative

• Timely submission of documentation

• Obtaining informed consent from member or legal representative

PERFORMANCE AND HEALTH OUTCOMES MEASUREMENT

Data will be collected quarterly in order to demonstrate that we are achieving our measurable goals, complying with our Model of Care and identifying any opportunities for improvement.

Data Sources: • Authorization and Referrals

• Case Management

• Medical Record Reviews

• Claims

• Credentialing Database

• Enrollment

• Member Services Calls and Surveys

• Pharmacy Reports

• Provider Surveys

• GEO Access Surveys

• Provider Appointment Availability Studies

• HRAs

• Health Outcome Surveys

• Health Outcome Data

THINGS TO REMEMBER

• Nurse Practitioner (NP) authorizes ALL services for I-SNP and IE-SNP.

• NP works directly with PCP to assure that needed services are in place and visits the member at either the facility (Nursing Home/ALF) or at home.

• NP can order labs, diagnostic test and prescribe medications for I-SNP and IE-SNP. (If physician agrees)

• Care Manager works with the physician to ensure that the services are in place and assists in disease management. Contact is only via telephone. (D-SNP)

• Every SNP member that participates in the Care Management program will have a Care Plan and a Health Risk Assessment.

• Care Management is REQUIRED for I-SNP and IE-SNP.

• Care Management is OPTIONAL for D-SNP.

• Interdisciplinary Care Team is the cornerstone to Model of Care and requires participation from providers.

LOURDES GAYO

1701 PONCE DE LEON BLVD.

MIAMI, FLORIDA 33134

786-441-4785

Questions? Comments? We are happy to help you!