FIDA Model of Care Implementation and Accountability | 3 Elements - PowerPoint PPT Presentation

FIDA Model of Care

Implementation and Accountability | 3

Elements of a Model of Care All FIDA Plans are required to implement a Model of Care with detailed and in-depth responses to the eleven (11) NCQA elements and one element required by NYSDOH Element 1 Description of the SNP-specific Target Population Element 2 Measurable Goals Element 3 Staff Structure and Care Management Roles Element 4 Interdisciplinary Care Team (ICT) Element 5 Provider Network having Specialized Expertise and Use of Clinical Practice Guidelines and Protocols Element 6 Model of Care Training for Personnel and Provider Network Element 7 Health Risk Assessment (HRA) Element 8 Individualized Care Plan Element 9 Communication Network Element 10 Care Management for the Most Vulnerable Subpopulations Element 11 Performance and Health Outcome Measurement Element 12* Self-Directed Services * Note: Element 12 required by the NYSDOH. | 4

Measurable Goals and Performance and Health Outcome Measurement (Elements 2 and 11) Overall Care Management Goals Specific Care Management Goals for FIDA Members (By Year 1 or Year 2) Improve access to essential services  95% of members will have annual physical exams such as medical, mental health, and  100% completion of comprehensive assessments within 30 days social services of enrollment  Exceed HEDIS national benchmark for members hospitalized for depression who receive outpatient visit with mental health provider within 30 days of discharge Improve access to affordable care  Generic dispensing rate of 76%  Maximize access to supplemental benefits that reduce member out-of-pocket costs Improve coordination of care through an  100% of new members assigned a care manager within 30 days identified point of contact of enrollment Improve seamless transitions of care  Transitional care nurse for all members with a care transition across healthcare settings, providers,  Notify all PCPs within 1 business day of notice of care transition and health services Improve access to preventive health  Increase colorectal cancer screening rate to meet/exceed U.S. services average benchmark  Smoking cessation support for self-identified smokers Assure appropriate utilization of  Improve ACE/ARB medication adherence of diabetic members services  Reduce readmission rates to 19% Improve beneficiary health outcomes  Improve ACE/ARB medication adherence of diabetic members

Measurable Goals and Performance and Health Outcome Measurement (Elements 2 and 11) Sample of Reports Used for Performance and Health Outcome Measurement Report Frequency Primary Use Related to MOC A&G Committee Dashboard Monthly Identify trends and areas for improvement in member dissatisfaction (complaints, appeals) Assessment Data Bi-monthly Ensure 100% completion of assessment within 30 days Clinical Practice: Gaps-In- Quarterly Identify member gaps in preventive care Care Report Frequent Flier Report Monthly Identify vulnerable members (for discussion at ICT meeting) Lab Utilization Ad hoc Identifies non-par lab utilization Pharmacy & Therapeutics Quarterly Identify vulnerable members (medication adherence, high-risk Committee Reporting medication); Formulary design/changes (generic dispensing rate, tier/non-formulary exceptions requested and approved) Procedure Frequency Report Yearly Utilization of services by members (Part C & D Reporting) Re-Admissions Report Monthly Identify vulnerable members (for discussion at ICT meeting) Major areas identified by CMS/plan for improvement: Need to develop methods for measuring or determining goal achievement of health outcomes (including benchmarks) | 6 and enhance methods for communicating measurements/outcomes to stakeholders.

FIDA MOU Requirements for Care Management* MOU Care Management Requirement Corresponding MOC Element Comprehensive Assessment Health Risk Assessment (Element 7) Person-Centered Service Plan Individualized Care Plan (Element 8) Interdisciplinary Team (IDT) Interdisciplinary Care Team (Element 4) Self-Direction Self-Directed Services (Element 12) * Note: these requirements are detailed on pages 60-64 of the MOU. | 7

Health Risk Assessment (Element 7)  Timely comprehensive assessment of medical, behavioral health, community- based or facility based LTSS, and social needs; must be completed within 30 days of enrollment – HSF: self-reported; upon enrollment into plan – UAS: completed by RN in individual’s home Assessment results used to develop Care Plan and to determine appropriate  acuity/risk stratification level Re-assessments  – As warranted by member’s condition, but at least every 6 months after initial assessment – Change in member’s health status or needs – As requested by member, caregiver, or provider – Trigger events: hospital admission, transition between care settings, change in functional status, loss of a caregiver, change in diagnosis, as requested by ICT member who observes a change that requires further investigation | 8

Individualized Care Plan (Element 8)  Care Plan created within 30 days of assessment Care Plan reviewed and revised within 30 days of reassessment  Care Manager works with the member and the ICT to develop a care plan that  identifies and meets the member’s specific medical, cultural, linguistic, service, and equipment needs  Components of a Care Plan: – Results of health risk assessments – Problems – Goals – Interventions – Specific services and benefits – Preferences for care Major area identified by CMS/plan for improvement: Care Plan should include add- on benefits/services for vulnerable beneficiaries. | 9

Interdisciplinary Care Team (Element 4)  Every Elderplan member is assigned a care manager and an interdisciplinary care team (ICT)  The ICT, led by the care manager, ensures the integration of the member’s medical, behavioral health, substance abuse, community-based or facility based LTSS, and social needs Care Manager (RN or Social Workers) Social Work Enrollment RN Medicaid Specialist Providers Plan (Primary/specia Member lty care, Medical pharmacist, Director personal care, rehabilitation, etc.) Quality Family and and Home Wellness Supports Team Member Services Major areas identified by CMS/plan for improvement: Outreach to members and | 10 member education/resources

Self-Direction (Element 12)  Members who opt to participate in the consumer-directed personal assistance option can choose their own Personal Care Worker (PCW) The member and/or designated representative is responsible for hiring, training,  supervising, and, if necessary, terminating the employment of this PCW Members, their PCPs, and their designated representatives will be educated on  consumer-directed options at two time points: (1) Upon enrollment (2) Semi-annual reassessments Major areas identified for improvement: Need to enhance how organization will monitor education efforts and how the organization will evaluate the self-directed services. | 11

Care Management for the Most Vulnerable Subpopulations (Element 10) Vulnerable Subpopulations: Members with severe chronic or disabling conditions  – Data used to identify population: health risk assessments, diagnosis and procedures, DME utilization, drug utilization, sensory impairment, impaired mobility  Members with high frequency usage of services – Data used to identify population: health risk assessments, ambulatory care, inpatient utilization, surgical procedures, BH utilization, length of stay Members with social and environmental factors that could limit access to effective  care – Data used to identify population: health risk assessments, transportation use, PCW hours, provider network adequacy, complaints Members nearing the end of life  Major area identified by CMS/plan for improvement: Need to enhance add-on services/benefits provided to the most vulnerable populations (e.g., specialized case management). | 12

Care Management for the Most Vulnerable Subpopulations (Element 10): Case Study 82 year old male with history of prostate cancer (first diagnosis in 1990);  cancer spread to the bone in 2012 In 2013 member’s Prostate Specific Antigen (PSA) test rose above 225  and member experienced an increase in bone pain – Member was started on morphine and was referred to radiation oncology for additional palliative treatment – Radiation Oncologist recommended a novel medication (Xofigo, just approved by the FDA three months ago) that was shown in randomized studies to decrease bone pain and extend life by several months Opportunity for specialized case management  | 13