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

FIDA Model of Care

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Implementation and Accountability

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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.

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 such as medical, mental health, and social services

• 95% of members will have annual physical exams
• 100% completion of comprehensive assessments within 30 days
• f 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
• ut-of-pocket costs

Improve coordination of care through an identified point of contact

• 100% of new members assigned a care manager within 30 days
• f enrollment

Improve seamless transitions of care across healthcare settings, providers, and health services

• Transitional care nurse for all members with a care transition
• Notify all PCPs within 1 business day of notice of care transition

Improve access to preventive health services

• Increase colorectal cancer screening rate to meet/exceed U.S.

average benchmark

• Smoking cessation support for self-identified smokers

Assure appropriate utilization of services

• Improve ACE/ARB medication adherence of diabetic members
• Reduce readmission rates to 19%

Improve beneficiary health outcomes

• Improve ACE/ARB medication adherence of diabetic members

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Measurable Goals and Performance and Health Outcome Measurement (Elements 2 and 11)

Sample of Reports Used for Performance and Health Outcome Measurement Major areas identified by CMS/plan for improvement: Need to develop methods for measuring or determining goal achievement of health outcomes (including benchmarks) and enhance methods for communicating measurements/outcomes to stakeholders.

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- Care Report Quarterly Identify member gaps in preventive care Frequent Flier Report Monthly Identify vulnerable members (for discussion at ICT meeting) Lab Utilization Ad hoc Identifies non-par lab utilization Pharmacy & Therapeutics Committee Reporting Quarterly Identify vulnerable members (medication adherence, high-risk medication); Formulary design/changes (generic dispensing rate, tier/non-formulary exceptions requested and approved) Procedure Frequency Report (Part C & D Reporting) Yearly Utilization of services by members Re-Admissions Report Monthly Identify vulnerable members (for discussion at ICT meeting)

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FIDA MOU Requirements for Care Management*

* Note: these requirements are detailed on pages 60-64 of the MOU.

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)

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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

• f 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

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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-

• n benefits/services for vulnerable beneficiaries.

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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 Major areas identified by CMS/plan for improvement: Outreach to members and member education/resources

Member

Care Manager

(RN or Social Workers)

Social Work Medicaid Specialist Plan Medical Director Family and Home Supports

Member Services

Quality and Wellness Team Providers

(Primary/specia lty care, pharmacist, personal care, rehabilitation, etc.)

Enrollment RN

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Self-Direction (Element 12)

• Members who opt to participate in the consumer-directed personal assistance
• ption 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.

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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).

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• 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

• ncology 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

Care Management for the Most Vulnerable Subpopulations (Element 10): Case Study

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Provider Network and MOC Training for Personnel and Providers (Elements 5 and 6)

• Provider Network Requirements

– Specialized expertise that corresponds to target population – Actively licensed and competent – Use evidence-based clinical practice guidelines and nationally recognized protocols

• Required Annual Training for Employees and Providers

– MOC training for all new employees in orientation; effective 2014, training will be provided via E-Learning module on Intranet – MOC training for new participating providers conducted as part of face-to- face orientation; self-study training materials available on Provider Portal (advertised on Web site and in Provider Newsletters)

Major areas identified by CMS/plan for improvement: Need to ensure provider network corresponds to needs of target population; Implementation and assurance

• f completion of employee and provider training

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Continuous Improvement Process