2007 Model of Care – Community Health Plan Medicare Advantage

150 Pages·2012·3.99 MB·English

by  Michael Hays

Medicare Advantage Special Needs Plan
Model of Care

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Table of Contents
Introduction ................................................................................................................................... 3
Description of the SNP Specific Target Population ...................................................................... 4
Goals and Objectives ..................................................................................................................... 4
Staff Structure & Care Management Roles ................................................................................... 8
Care Management Organization ....................................................................................... 20
Interdisciplinary Care Team (ICT) .............................................................................................. 28
Interdisciplinary Care Team (“ICT”) and Care Coordination ..................................................... 29
Provider Network having Specialized Expertise & Use of Clinical Practice Guidelines &
Protocols ...................................................................................................................................... 42
Professional License ......................................................................................................... 44
Board Certification............................................................................................................ 44
State Sanctions and Medicare and Medicaid Sanctions .................................................... 45
Medicare Status ................................................................................................................. 45
Ongoing Monitoring ......................................................................................................... 45
Medicare and Medicaid Sanctions .................................................................................... 46
Sanctions or Limitations on Licensure ............................................................................. 46
Practitioner Specific Member Complaints ........................................................................ 47
Identified Adverse Events ................................................................................................. 47
Clinical Measures Service Measures and Practitioner Utilization Patterns ...................... 47
Pending Malpractice Suits ................................................................................................ 48
Medicare Opt –Out List .................................................................................................... 48
Monitoring as Necessary................................................................................................... 48
Assessment of Organizational Providers .......................................................................... 49
Organizational Provider Application Criteria Evaluation................................................. 49
Organizational Provider Tri-Annual Reassessment .......................................................... 51
Tracking Spreadsheet ........................................................................................................ 52
Clinical Expertise .............................................................................................................. 54
Use of Non-Network Specialists ....................................................................................... 54
Clinical Guideline Development....................................................................................... 55
Ensuring Consistency........................................................................................................ 56
Audits .......................................................................................................................................... 56
Oversight ..................................................................................................................................... 56
Model of Care Training for Personnel & Provider Network ....................................................... 56
Overall CHPW Information .............................................................................................. 56
HR & Benefits................................................................................................................... 56
Insurance Industry ............................................................................................................. 57
Resources & Referrals ...................................................................................................... 57
Community Health Plan of Washington Departmental Interface & Workflow
Coordination ..................................................................................................................... 57
CHC Interface ................................................................................................................... 58
Paraprofessional Skills Development ............................................................................... 58
Documentation .................................................................................................................. 58
Health Risk Assessment .............................................................................................................. 59
Individualized Care Plan ............................................................................................................. 67
Communication Network ............................................................................................................ 96
Service Delivery System ............................................................................................................. 96
Innovating for Health Care Reform ............................................................................................. 97
Care Management for the Most Vulnerable Sub Populations ..................................................... 99
Performance and Health Outcome Measurement ...................................................................... 104
APPENDICIES ......................................................................................................................... 115
Revision History ........................................................................................................................ 149
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Introduction

Community Health Plan of Washington has specialized in Medicaid managed care since 1996. Today, we
serve approximately 180,000 beneficiaries of Washington’s Healthy Options program. We serve an
additional 60,000 low-income Washington residents through the state’s Basic Health program, the
state’s Children’s Health Insurance Program, and the Medical Care Services (Disability Lifeline /
General Assistance - Unemployable program). In total we manage the care of roughly 260,000 low-
income beneficiaries through our contracts with the state of Washington.

CHPW is an affiliate of Community Health Network of Washington, an affiliation of 19 Community
Health Centers (CHCs) across the state of Washington, all of which are Federally Qualified Health
Centers (FQHCs). As safety net providers, the CHCs take all comers, including managed care, fee-for-
service and uninsured patients. In 2004, these CHCs collectively recorded serving 200,000 uninsured
patients, 215,000 Medicaid patients, and 27,000 Medicare beneficiaries, roughly one-third (i.e.; 9,000)
of whom were dually eligible for Medicaid. Over the past several years, the number of Medicare
beneficiaries seeking care at the CHCs has increased on average between 15 and 20% per year.

Based on our mission of providing quality health care to the underserved, our tenure in serving
Medicaid beneficiaries, and our strong connection to the CHCs we remain uniquely positioned to serve
Dual-Eligible beneficiaries and high risk populations

We are acutely aware that dual-eligible beneficiaries in the state of Washington have relatively
comprehensive health insurance coverage with no out-of-pocket responsibility through Original
Medicare and fee-for-service Medicaid. Thus, it was challenging to design a SNP benefit package that
offers beneficiaries better value than Original Medicare. When we entered the market in 2007 we
implemented a new concept based on an enhanced service approach: the Patient Navigator (PN) model.
The SNP model of care has been in many ways a natural extension of our ongoing efforts at population
management.

We believe that this concept has distinguished us from both Original Medicare and our SNP competitors,
and affords beneficiaries and their families with a unique and highly valuable improvement in their
Medicare experience. We essentially changed our competitive position from one based on supplemental
benefits (i.e.; rebate allocation) to one based on medical management infrastructure (i.e.; patient
centered care). As such, we are the first SNP in Washington State available in 28 counties across the
state and are adding two additional counties to bring the total to 30.

Our system of care, to be outlined in detail below, reflects pertinent clinical expertise and staff
structures to support quality care for this population. Our processes of care meet or exceed the goals
and objectives for initial and periodic assessment, care and case management, and process/outcome
measures to evaluate our performance.

Below we detail our Population management plan as relevant to the SNP Model of Care that has been in
place since 2007, our first year serving Medicare beneficiaries as a Medicare Advantage Organization
and precede the layer in the Model of Care requirements.

Through 2009, for our SNP product, the work of the Patient Navigators remained unique in its content
and value. Patient Navigators (now Integrated Care Management Specialists or ICMS) assist our dually-
eligible SNP members understand and access Medicaid-only benefits which, in Washington, are paid for
by the State in a highly uncoordinated fee-for-service environment.

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In 2012 we are continuing a mandatory supplemental dental benefit for our SNP. While Medicaid covers
dental in Washington, market research indicated that dually-eligible beneficiaries faced difficulty finding
dentists who would accept the Medicaid fee schedule.

We have devoted a significant portion of our rebate toward providing a comprehensive dental benefit
with a $1,200 annual limit, believing that doing so will provide alternative care and open access to
dental care and help improve the overall health of this special needs population.
Description of the SNP Specific Target Population
The Dual Medicare Advantage Special Needs Population has several Medicare Program options, but
unlike all other Medicare beneficiaries who may leave a plan only at certain times, dual eligibles
(Medicare & Medicaid) may leave a plan at any time. The Dual Medicare Advantage SNP at Community
Health Plan of Washington, [The Plan], is comprised of enrollees who are typically older, often disabled,
with multiple co-morbidities, including cancer, congestive heart failure, hypertension, obesity,
dementia, and diabetes. Some of the enrollees require transplant services, Skilled Nursing, and Long
Term Care to maintain or survive, while others need Hospice and End of Life Care.

The Plan’s Dual Medicare Advantage SNP members were responsible for 68% of all Urgent requests for
Skilled Nursing Facility or Long Term Care admissions across the entire spectrum of Medicare plans
offered. The top three and most prevalent co-morbidities of this population include Type II Diabetes,
Benign Hypertension, and Hyperlipidemia. These members are also more likely to experience joint
degradation, psychotic, schizophrenic and mood disorders, and represent the most vulnerable and frail
of all lines of business.

Examples include but are not limited to:

Beneficiaries disconnected from care as evidenced by lack of a PCP or Specialty visit within the
last 6-12 months
Beneficiaries with the highest evidence of illness as identified by risk score, claims, and
pharmacy data
Beneficiaries with high behavioral health, functional or emergent psychosocial needs, including
the frail and elderly and those requiring palliative care.
Beneficiaries requiring special education such as fall prevention, disease management, or
education regarding plan services and community resources.

MA Contract Name: Community Health Plan of Washington
MA Contract Number: H5826 - 005
Type of Dual-eligible SNP: Full Dual-Eligible

(We are not serving beneficiaries with end-stage renal disease [ESRD] unless they are diagnosed with
ESRD after they have enrolled.)
Goals and Objectives
For several care management goals, we have not been successful in accessing robust benchmarks. Due
to this difficulty, and consistent with NCQA practices, we have set a percentage improvement target or
goal based on current performance. This is to be considered our default measure if applicable
benchmarks are found to be unavailable or fully applicable.

Improving access to medical, mental health and social services:
This is indirectly measured by third out data with a set goal of a 3% improvement year-over-year.

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Improving access to affordable care:
Beginning In 2011, the Plan will indirectly measure by analysis of complaints data regarding medication
cost with a goal of ensuring availability of generic alternatives.

Improving transitions:
Beginning In 2011, ensure at least 50% of members get an appointment with their PCP or
Behavioral Health provider within 7 days of hospitalization for mental health diagnosis (HEDIS
Measure FUH).

Improving access to preventive care:
Beginning In 2011, Care coordination by ICMS staff to ensure 75% of all members have an initial PCP visit
within two months of their initial treatment plan. The Plan will review claims data on a quarterly basis
and evaluate CPT codes for office visits.

Assuring appropriate utilization:
Beginning In 2011, the Plan will monitor on a quarterly basis IP, OP procedures and ER utilization
as compared against available Milliman benchmarks to ensure over under utilization is not
apparent. The goal if found is set at +/- 3% of applicable Milliman benchmark. Lacking an
available benchmark the Plan will set its goal not to exceed +/- 3% of a 3 year rolling average
beginning 2008 to current date.

Improving health outcomes:
Beginning In 2011, reduce hospitalizations, readmissions, and ER visits by 3% improvement year-over-
year.

The Plan’s measurement activities in 2011 include an analysis of information gathered from several data
sources, including CAHPS (Getting Needed Care), Medicare HOS (Health Outcome Survey Measures),
Custom Quarterly Member Satisfaction survey with a focus on access to Specialty care and getting
appointments as soon as members thought they needed, Customer Complaints and Appeals, and the
Provider Satisfaction survey with a focus on UM and Case Management, to determine if goals and
objectives regarding access to affordable care are being met. The Plan set its performance goals to
achieve The Myers Group Book of Business 75th Percentile, where applicable, or the NCQA Quality
Compass HEDIS Means and Percentiles, 75th Percentile. These data sources are selected due to their
consistent methodology of collection, analysis and reporting across all participating plans. The results of
all surveys are reported to the Quality Council and identified opportunities for improvement are
recommended to this committee. The Quality Council reviews the analysis and recommendations, and
provides guidance for the corrective action plan. An example of an opportunity that was the result of an
analysis of customer and provider complaints revealed the Plan received an unusual amount of return
mail. The content of those mailings were not being delivered to some members and providers. The
findings of a subcommittee established to understand the extent of the problem made
recommendations to remove barriers in the following areas:

Mail Management Resources like mail management resources dedicated to
manage mail issues
Administrative Interventions like improving address management in Xcelys the
Plan claims transaction processing system
Interventions that target Members like promoting the member portal
(incentivize members)
Interventions that target the State like Collaborating to improve the eligibility
roster process

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The Plan examines data gathered in support of SNP4 as performance metrics for coordination of care
through an identified point of contact, and assisting members through seamless transitions. The plan
establishes a goal of ensuring 80% of all notifications is communicated within the specified timeframe.
Examples include an analysis of:

Notification to Members’ providing contact information, types of services and resources
available within 2 business days of receiving hospital notification.
Notification to Members’ PCP that the member has transitioned from the medical home into the
hospital, skilled nursing, or long term care facilities within 1 business day of receiving hospital
notification.
Notification to Admitting and Treating Physicians of the requirement to share the care plan or
changes in health status with the sending or receiving facility within 1 business day of receiving
hospital notification.

In addition, the Medicaid subset of the Dual-SNP population is analyzed in great depth utilizing an
industry standard predictive modeling tool, Symmetry from Milliman. True characterization of the
population is achieved by fully leveraging the power of predictive risk scores; episode treatment groups
and health cost and utilization categories. Medicare and Medicaid characteristics of the population are
fully leveraged as we design our interventions to best access all available resources for our QMB Plus
(Qualified Medicare Beneficiary) and SLMB Plus (Specified Low-Income Medicare Beneficiary) member
populations with access to full Medicaid coverage in addition to Medicare.

Predictive risk scores allow us to triage available resources and reach out and access those at highest
health risk and ensure all access needs are fully met. Episode treatment groups and health cost
categories aggregate available claims data into a useable format driving our full understanding of
needed services and drive our focused interventions. For example, one of the desired outcomes of these
activities and ultimate measure of success remains a reduction in hospitalizations and readmissions.

The Plan reviews the results of selected HEDIS measures as a proxy for beneficiary health outcomes.
Examples may include but are not limited to:

Comprehensive Diabetic Care (CDC)
Controlling High Blood Pressure (CBP)
Antidepressant Medication Management (AMM)
Medication Reconciliation (MRP)

Case Study #1: The Plan identified several responses on the health risk assessments where members
reported feeling ‘sad and blue’. This is a single item depression screen that was developed and
validated at Johnson Hopkins and is in wide use. A positive endorsement of feeling ‘sad and blue’ is
often indicative of clinical depression.

Based on the finding that many of our members endorse this item on their HRA, a set of processes was
implemented in December 2010 which allow us to further assess for clinical depression and make
appropriate treatment recommendations as indicated.

Case Study #2: Evaluations of the Plan’s Case Management effectiveness revealed when members are
enrolled in the case management program and adhere to care plan goals there are fewer unplanned
admissions and readmissions. Potential causes of readmissions included missing medication lists, post
surgical care instructions were confusing or not given, little or no communication existed between
physicians when a patient was switched from one facility to another, and/or follow up appointments
were never made or communicated.

In 2010, the Plan found its implementation of a process that provided immediate follow-up after a
hospitalization with the member to assess for possible complications at discharge with the care plan or
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with medications is having a positive impact on reducing readmissions. As a result the Plan will continue
its effort to identify barriers and implement more affective interventions. There is some evidence that
suggests the longer a member remains enrolled and compliant the greater reduction of unplanned
services.

In addition the Medicaid subset of the Dual-SNP population is analyzed in great depth utilizing an
industry standard predictive modeling tool, Symmetry from Milliman. True characterization of the
population is achieved by fully leveraging the power of predictive risk scores; episode treatment groups
and health cost and utilization categories. Medicare and Medicaid characteristics of the population are
fully leveraged as we design our interventions to best access all available resources for our QMB Plus
(Qualified Medicare Beneficiary) and SLMB Plus (Specified Low-Income Medicare Beneficiary) member
populations with access to full Medicaid coverage in addition to Medicare.

Predictive risk scores allow us to triage available resources and reach out and access those at highest
health risk and ensure all access needs are fully met. Episode treatment groups and health cost
categories aggregate available claims data into a useable format driving our full understanding of
needed services and drive our focused interventions. For example one of the desired outcomes of these
activities and ultimate measure of success remains a reduction in hospitalizations and readmissions.

The Plan reviews the results of selected HEDIS measures as a proxy for beneficiary health outcomes. The
Plan’s goal is to reach and maintain the 90th Percentile of the NCQA Quality Compass Means and
Percentiles for these measures. One of the Plan’s proposals to achieve these goals includes developing
monthly score cards with indices that include for example Diabetic Labs and examining claims to
measure PCP visits within a specified timeframe after hospitalizations, contacting those members to
ensure they are fully aware of their treatment options and motivating them to take advantage of free
services. Examples of indicators may include but are not limited to:

Comprehensive Diabetic Care (CDC)
Controlling High Blood Pressure (CBP)
Antidepressant Medication Management (AMM)
Medication Reconciliation (MRP)

Provider Services with oversight activities regarding
Increase access to medical, mental access to care. Quality Improvement third out data
health & social services as self reported by the network.
3% Increase in Coordination of Care. Survey
Increase coordination of care with enrollees for PCP and access information. Track PCP
an identifiable point of contact visits at time of risk stratification.
3% Reduction in lag time to PCP notification, and lag
Improve transitions across settings time to appointment with PCP or Psych provider
& providers from time of discharge.
Improve access to preventive 3% increase in preventive health visits with the PCP
health services team
Assure appropriate utilization 3% Reduction in ER visits
Improve health outcomes 3% Reduction in Admission Rates
3% Reduction Readmission Rates

When an opportunity for improvement is identified through annual analysis, monthly evaluation and
monitoring performance indicators or from other sources, The Plan’s non-emergent process of
corrective action includes collection of data, systematic description and measurement, identification of
possible root causes of barriers to success, development and implementation of potential interventions,
annual re-measurement and analysis.

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Emergent issues that impact service, access, and timeliness of communication that the Plan has
identified is the result of internal process error is addressed via the same process in an abbreviated time
frame.

For example, in 2010 when the Plan determined its current written communication to assist the sharing
of the member’s care plan or changes in health status was communicated between the PCP, Treating
and Admitting physicians was not happening in a timely manner, it acted immediately to implement
letters to address the gap in process.

ER Utilization Case Study: Contributing factors to the initial spike in services include members getting
deferred care some requiring ER utilization. In spite of exceeding the targeted goal by 19.7 percentage
points our interaction with those in CM and the nature of ailments resulting in ER visits lead us to
believe, that a continued effort is appropriate identifying opportunities to further reduce ER utilization
and the member’s exposure to the hospital environment.

Identified opportunities for improvement:

Barrier/Opportunity #1: Do not have a direct means of educating and encouraging good health
utilization habits of new and existing members.

Interventions:

Case Management updated the initial assessments for both the Adult and Pediatric population in Q2
of 2010 to include:
1.) A discussion of ER utilization,
2.) How to establish / maintain a medical home,
3.) Appropriate access to services and benefits.
4.) Updated the Integrated Care Management Specialist (ICMS) review tool to reflect ER utilization
patterns along with pharmacy claims.

When an opportunity for improvement is identified through monitoring performance indicators or from
other sources, The Plan’s process of corrective action includes collection of data, systematic description
and measurement, identification of possible root causes of barriers to success, development and
implementation of potential interventions, re-measurement and analysis.
Staff Structure & Care Management Roles

Administrative Roles:

Enrollment, Eligibility, Marketing, Claims Processing, Customer Service and other
administrative departments will operate as per The Plan’s Policy & Procedures and CMS
contracting requirements for any and all SNP beneficiaries as they would for any other
Community HealthFirst (Medicare) / Community Health Plan of Washington (all other
LOBs) enrollee.

Medicare Enrollment Coordinator works closely with Customer Service Representatives,
Finance, Medicare Sales Representatives, Grievance & Appeals Coordinators, internal and
external IT service technicians, Quality Assurance Coordinators, Third Party Administrators, and
Federal and State agencies.
This position is responsible for the Medicare Advantage plan enrollment & disenrollment
process and ongoing membership maintenance in accordance with CMS guidelines. This
position involves high level critical-thinking skills with the ability to recognize, analyze, and
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resolve Medicare Enrollment problems. This position may also assist with non Medicare
Eligibility Department duties on an as needed basis with other products such as Healthy Options,
CHIP, Disability Lifeline, Washington Health Program and Basic Health.

Principal Duties:
Within Community Health Plan- and CMS-mandated time-frames:

A. Review enrollment applications and determine completeness as well as verify all aspects
that determine eligibility for plan choice, election type and effective date per the
Medicare Managed Care Manual, Chapter 2.
B. Process enrollments into the system, including compiling data and creating complex
letters.
C. Review all Part D enrollment applications for Creditable Coverage Period
Determinations and the Late Enrollment Penalty and compile data needed for the
required letters & forms.
D. Review and process all disenrollment and related requests and determine completeness
as well as verify all aspects that determine eligibility for the requests.
E. Ensure CMS acceptance of all enrollment, disenrollment and change transactions by
identifying submission errors and making corrections as necessary
F. Using provider network knowledge, (or by member request) assign Primary Care
Provider (PCP)
G. Resolve general eligibility, ID card, pharmacy access, issues and concerns raised by the
plan, clinics, TPA, CMS or member. Research and take appropriate actions as necessary.
H. Communicate, both orally and in writing, with CMS, CMS contractors, other internal
departments, plan TPAs, and members about complex issues when necessary.
I. Respond to eligibility queries from Medicare Sales regarding potential enrollees
J. Compile data for and create letters to members with terming PCPs and/or Specialist
K. Other duties as assigned

Qualifications:

Education: BA in related field, or equivalent work experience. Individual demonstrated
computer literacy.

Prior Related Experience: Two or more years experience working within a managed care
environment. Two years involvement with eligibility processes and procedures preferred. Two
years experience or greater working with Medicare required. Experience with Healthy Options
and Basic Health required.

Knowledge, Skills, and Abilities:

Complete knowledge and understanding of CMS Medicare Enrollment/Disenrollment
Guidance, Creditable Coverage Period Determinations & Late Enrollment Penalty
Guidance, Best Available Evidence Guidance, and other policies as appropriate.
Ability to research and analyze complex issues regarding enrollment, file processing, and
letter creation/generation
Minimum 2 years experience in reading data files
Demonstrated ability to prioritize work and function efficiently with little supervision.
Ability to develop innovative solutions to create and improve processes.
Must be able to exercise discretion, tact, and respect for confidentiality.
Must be able to work with a variety of people and circumstances.
Excellent demonstrated written and oral communication skills.
Ability to work individually as well as within a team environment.
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Knowledge of standard office practices and procedures.
100% Team Player Participation.

Other: Eligible to participate in local, state and federal health care programs including Medicare
and Medicaid.

Eligibility Clerk is responsible for data entry supporting eligibility and enrollment coordinators as
well as the eligibility analyst. This person may also be asked to do other organizational duties
such as filing, assisting EC’s with printing and assembling member letters and materials and
other duties as assigned.

Principal Duties:
Within plan- and state-mandated time-frames:
Create eligibility records in the system
Process Primary Care Provider (PCP) change requests
Communicate orally and in writing with state, other departments, and members when
necessary
Assist in preparation of letters to members with terming PCPs and/or Specialist
Other duties as assigned.
Qualifications:
Education:
High School graduate or equivalent.
Demonstrated computer literacy required.

Prior Related Experience
Two or more years experience working within a managed care environment.
Two years involvement with eligibility processes and procedures strongly desired.
Experience with Medicare, Medicaid and other state programs preferred.

Employment Eligibility:
Candidate has not been sanctioned or excluded from participation in federal or state
healthcare programs by a federal or state law enforcement, regulatory, or licensing agency.

Knowledge, Skills, and Abilities
Proficiency with Microsoft Word, Excel, and Access.
Strong attention to detail.
Demonstrated ability to prioritize work and function efficiently with little supervision.
Ability to develop innovative solutions to create and improve processes.
Proven ability to analyze complex documents and develop resulting solutions.
Must be able to exercise discretion, tact, and respect for confidentiality.
Must be able to work with a variety of people and circumstances.
Excellent demonstrated written and oral communication skills.
Ability to work individually as well as within a team environment.
Excellent reading skills.
Excellent interpersonal skills.
Knowledge of standard office practices and procedures.
100% Team Player Participation.

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