Care Management through Special Needs Plans

Presentation Transcript



Care Management through Special Needs Plans SNP Model of Care and Quality Improvement Program - May 2009

Special Needs Individuals As of January 1, 2010, all SNP enrollees must qualify as: Dually qualified for Medicare and Medicaid advantages and administrations or Institutionalized or institutional identical dwelling in the group or Having certain CMS-endorsed extreme or impairing interminable conditions SNP Model of Care and Quality Improvement Program - May 2009

SNP Model of Care The SNP Model of Care is the design for care administration approach, methodology, and operational frameworks. SNP Model of Care and Quality Improvement Program - May 2009

SNP Model of Care Gradual advancement of SNP Model of Care in enactment and CMS direction: MMA of 2003 Established SNPs 2007 Call Letter Established system of specialized suppliers, utilize of clinical practice guidelines, objectives, staff structure and parts, & communication organize SNP Model of Care and Quality Improvement Program - May 2009

SNP Model of Care 2008 Call Letter Established preparing for suppliers MIPPA of 2008 Mandated wellbeing hazard assessment, mind arrange, interdisciplinary watch over recipients, & evaluation of care effectiveness SNP Model of Care and Quality Improvement Program - May 2009

Model of Care Elements 1) Measurable Goals 2) Staff Structure & Care Management Roles 3) Interdisciplinary Care Team 4) Provider Network Having Special Expertise and Use of Clinical Practice Guidelines 5) Model of Care Training 6) Health Risk Assessment 7) Individualized Care Plan 8) Communication Network 9) Performance & Health Outcome Measurement SNP Model of Care and Quality Improvement Program - May 2009

CMS Oversight MAO has a composed care administration arrange for that depicts the model of care MAO archives usage of nurture CMS survey amid reconnaissance exercises and reviews MAO conforms to SNP-particular reporting prerequisites SNP Model of Care and Quality Improvement Program - May 2009

SNP Model of Care Goals SNP Model of Care and Quality Improvement Program - May 2009

SNP MOC Goals Improve access to therapeutic, emotional well-being, and social administrations Improve access to reasonable care Improve coordination of care through a recognized purpose of contact Improve moves of care crosswise over human services settings and suppliers Improve access to preventive wellbeing administrations SNP Model of Care and Quality Improvement Program - May 2009

SNP MOC Goals Assure suitable use of administrations Assure savvy benefit conveyance Improve recipient wellbeing results Reduce hospitalizations and SNF situations Improve self-administration and freedom Improve versatility and utilitarian status Improve torment administration Improve personal satisfaction as self-reported Improve fulfillment with wellbeing status and wellbeing administrations SNP Model of Care and Quality Improvement Program - May 2009

SNP MOC Goals The composed care administration plan ought to address: MOC objectives are composed as quantifiable results How the MAO will realize that MOC objectives are met What moves the MAO will make if MOC objectives are not met SNP Model of Care and Quality Improvement Program - May 2009

Staff Structure and Care Management Roles SNP Model of Care and Quality Improvement Program - May 2009

Care Management Staff Plan authoritative staff (utilized or contracted) Provider organize (utilized or contracted) Interdisciplinary care group (utilized or contracted) Management staff (utilized or contracted) SNP Model of Care and Quality Improvement Program - May 2009

Care Management Roles CMS trusts MAOs have 3 fundamental care administration parts: Administer and facilitate benefits , arrange data, and information accumulation and examination Manage the conveyance of administrations and advantages Oversee managerial and clinical execution SNP Model of Care and Quality Improvement Program - May 2009

Administrative Roles MAO has authoritative staff (utilized or contracted) to: 1) Process enlistment 2) Verify qualification for extraordinary needs arrange 3) Process cases 4) Process and encourage determination of grievances and supplier protests 5) Communicate arrangement data SNP Model of Care and Quality Improvement Program - May 2009

Administrative Roles 6) Collect, break down, report, and follow up on performance and wellbeing result data Conduct quality change exercises Review and investigate use information Survey recipients and suppliers, and dissect comes about Report to CMS and States SNP Model of Care and Quality Improvement Program - May 2009

Service Delivery Roles MAO has benefit conveyance staff (utilized or contracted) to perform mind administration capacities: Advocate, advise, and teach recipients Identify and encourage access to group assets Triage mind needs Facilitates wellbeing hazard appraisal Authorize or encourage access to administrations Obtains discussion and demonstrative reports SNP Model of Care and Quality Improvement Program - May 2009

Service Delivery Roles MAO has benefit conveyance staff (utilized or contracted) to perform appraisal, finding, and treatment capacities: Medical and psychological wellness mind (equality) Social administrations (group based) Education on wellbeing dangers and care SNP Model of Care and Quality Improvement Program - May 2009

Service Delivery Roles MAO has benefit conveyance staff (utilized or contracted) to perform medicinal services data administration capacities: Assure upkeep and sharing of records and reports Assure HIPAA consistence Maintains paper-based or potentially electronic data frameworks SNP Model of Care and Quality Improvement Program - May 2009

MAO Oversight Roles MAO has administration staff (utilized or contracted) to screen mind administration capacities: Administrative capacities Monitor MOC usage Assure licensure and competency Assure statutory/administrative consistence Monitor legally binding administrations Evaluate MOC adequacy SNP Model of Care and Quality Improvement Program - May 2009

MAO Oversight Roles 2) Clinical Functions Monitors interdisciplinary care group Assures convenient and proper conveyance of administrations Assures suppliers utilize clinical practice rules Assures consistent moves and auspicious follow-up Conducts graph and additionally drug store audits SNP Model of Care and Quality Improvement Program - May 2009

Interdisciplinary Care Team SNP Model of Care and Quality Improvement Program - May 2009

MIPPA Mandate The MAO must allot EACH recipient to an interdisciplinary care group The MAO may outline a group contained utilized or contracted experts SNP Model of Care and Quality Improvement Program - May 2009

Role of the Team Analyze and consolidate the consequences of the underlying and yearly wellbeing hazard appraisal into the care arrange Collaborate to create and every year overhaul an individualized look after EACH recipient Manage the restorative, intellectual, psychosocial, and useful requirements of recipients Communicate to organize mind arrange SNP Model of Care and Quality Improvement Program - May 2009

Composition of the Team The interdisciplinary care group ought to negligibly include: Medical master Mental wellbeing as well as behavioral wellbeing master Social administrations master SNP Model of Care and Quality Improvement Program - May 2009

Composition of the Team Other care colleagues may include: Pharmacist Nursing proficient Restorative advisor Nutrition pro Medical pro Pastoral pro Health teacher Disease administration pro SNP Model of Care and Quality Improvement Program - May 2009

Composition of the Team MIPPA of 2008 orders cooperation of recipient as well as parental figure at whatever point plausible . Report prepare for having recipient/guardian on group in the care administration composed arrangement Document recipient/parental figure support when it happens SNP Model of Care and Quality Improvement Program - May 2009

Provider Network Having Specialized Expertise and Use of Clinical Practice Guidelines SNP Model of Care and Quality Improvement Program - May 2009

Provider Network Facilities: Acute care office Laboratory Radiography/imaging office Long-term mind office Rehab office Specialty outpatient centers SNP Model of Care and Quality Improvement Program - May 2009

Provider Network Providers with particular mastery: Medical pros (cardiology, psychiatry, neurologists, specialists, and so forth.) Behavioral authorities (medicate advisor, clinical analyst, and so on.) Nursing experts Allied wellbeing experts SNP Model of Care and Quality Improvement Program - May 2009

Provider Network MAOs must facilitate mind and guarantee that suppliers: Collaborate with the interdisciplinary care group Provide clinical discussion Assist with creating and redesigning care arranges Provide pharmacotherapy meeting SNP Model of Care and Quality Improvement Program - May 2009

Provider Network CMS anticipates that MAOs will: Prioritize contracting with board-ensured suppliers Monitor organize suppliers to guarantee they utilize broadly perceived clinical practice rules when accessible Assure that system suppliers are authorized and capable through a formal credentialing audit SNP Model of Care and Quality Improvement Program - May 2009

Provider Network CMS anticipates that MAOs will: Document the procedure for connecting recipients to administrations Coordinate the upkeep and sharing of recipient medicinal services data among suppliers, the interdisciplinary c