SNP Training Topic 3: Structure

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SNP Training Topic 3 Structure Process
Measures

• March 27, April 1, 2, 4, 2008

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Objective of SP Measures Training

• Describe the SNP evaluation project NCQA is
  executing on behalf of CMS
• Explain the intent of the SP Measures
• Determine what type of documentation to provide
• Demonstrate how NCQA will survey the measures.

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Goal for SNP Evaluation Program

• Robust and comprehensive assessment strategy
• Applies to all SNPs
• Responsive to the special in SNP
• Can be implemented soon

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Three-Year Strategy
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Project Time Line Phase 1

• March 14 - Release final SP measures
• April 15 - Release ISS Data Collection Tool
• S P Measures
• April 25 - Release IDSS Data Collection Tool
• HEDIS Measures
• June 30 - HEDIS submissions and SP measures
  submissions due to NCQA
• Sept 30 - NCQA delivers SNP Assessment Report to
  CMS

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Additional Resources

• NCQA SNP Web page www.ncqa.org/snp.aspx
• FAQs (HEDIS)
• Training descriptions schedule
• SP measures
• NCQA Policy Clarification Support (PCS)
• http//app04.ncqa.org/pcs/web/asp/TIL_Client
• Login.asp
• HEDIS Audit information
• http//www.ncqa.org/tabid/204/Default.aspx

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SNP Structure and Process Measures Brett Kay,
Director, Special Needs Plan AssessmentAisha
Pittman, Senior Health Care Analyst
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Overview of the SP Measures

• Start with known entities, raise the bar over
  time
• Phase one Define and assess desirable structural
  characteristics (Evaluate structure and process
  requirements through submission of documentation
  of policies and procedures
• Phase two Assess processes
• Phase Three Assess outcomes
• Apply to all SNP Types (dual, chronic,
  institutional)

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SP Measures

• Three Measures adapted from existing
  accreditation standards
• SNP 1 Complex Case Management
• Elements A-G
• SNP 2 Improving Member Satisfaction
• Elements A, B
• SNP 3 Clinical Quality Improvements
• Element A

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Components of the SP Measures

• Standard statement a statement about acceptable
  performance or results
• Intent statement A sentence that describes the
  importance of the SP measure
• Element The component of the measure that is
  scored and provides details about performance
  expectations. NCQA evaluates each element within
  the measure to determine the degree to which the
  SNP has met the requirements within the SP
  measure.

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Components of an SP Measure

• Factor An item within an element that is scored
  (e.g., an element may require an organization to
  demonstrate that a specific document includes 4
  items. Each item is a factor).
• Scoring The level of performance the
  organization must demonstrate to receive a
  specific percentage on each element (100, 80,
  50, 20, 0)
• Data source Types of documentation or evidence
  that the organization uses to demonstrate
  performance on an element. NCQA defines 4 types
  of data sources

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Data Source Types

• Documented Processes Policies and procedures,
  process flow charts, protocols and other
  mechanisms that describe an actual process used
  by the organization
• Reports Aggregated sources of evidence of action
  or compliance with an element, including
  management reports key indicator reports
  summary reports of analysis system output giving
  information minutes and other documentation of
  actions that the organization has taken
• Materials Prepared materials or content that the
  organization provides to its members and
  practitioners, including written communication,
  Web sites, scripts, brochures, review and
  clinical guidelines
• Records or Files Actual records or files, such
  as denial, appeal or credentialing flies that
  show direct evidence of action or compliance with
  an element---NCQA will not require file review
  for phase one.

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Components of an SP Measure

• Scope of Review The extent of the organizations
  services evaluated during an NCQA survey. Scope
  of review may vary
• Look-back period The period of time for which
  NCQA evaluates an organizations documentation to
  assess performance against an element
• Explanation Guidance for demonstrating
  performance against the element
• Example Descriptive information illustrating
  performance against an elements requirements.
  Examples are for guidance and are not intended to
  be all-inclusive

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SNP 1 Complex Case Management
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SNP 1 Complex Case Management

• The organization helps members with multiple or
  complex conditions to obtain access to care and
  services and coordinates their care
• NCQA Definition Complex Case Management
• The systematic coordination assessment of care
  services provided to members who have
  experienced a critical event or diagnosis that
  requires the extensive use of resources who
  need help navigating the system to facilitate
  appropriate delivery of care services

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SNP 1 Element A

• Identifying Members for Case Management
• Looking for evidence plans are culling from the
  applicable data sources to find members eligible
  for CM
• Data Sources
• claims or encounter data
• hospital discharge data
• pharmacy data
• laboratory results
• data collected through the UM process, if
  applicable
• Note NCQA looking to collect information on
  eligibility criteria used by plans for CM and
  data on of members enrolled in CM.

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SNP 1 Element A FAQs

• What type of information is NCQA looking for?
• Documented processes or reports that demonstrate
  the SNP is using various data sources to identify
  eligible members for CM
• What if a plan automatically enrolls all members
  in CM?
• Plans that auto-enroll all members in CM will
  receive 100 for this element
• What conditions qualify for entry into CM
  program?
• NCQA is not prescriptive. It is up to the SNP to
  design a program appropriate for its population.

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SNP 1 Element A Examples

• Documentation describes how the organization uses
  the specified data sources to determine if a
  member is eligible and may
• Feed information from these data sources into to
  a predictive modeling system
• Describe the member identification process flow
  and include resources case managers use such as
  discharge reports reports showing multiple
  admissions hospital history reports on past and
  present treatment lab reports reports from
  ancillary and/or behavioral health providers
  information on the members prognosis cost and
  utilization data catastrophic pharmacy claims
  disability claims and aggregate claims exceeding
  certain thresholds.

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SNP 1 Element B

• Access to Case Management Plan is open to
  referrals from other sources to consider members
  for CM
• Health information line referral
• DM program referral
• Discharge planner referral
• UM referral, if applicable
• Member self-referral
• Practitioner referral
• Other referrals

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SNP 1 Element B FAQs

• Does a SNP have to show all 3 data sources
  (documented processes, reports, materials) to
  receive credit?
• SNPs only need to show as many data sources as
  are needed to demonstrate compliance with the
  element. For example, promotional materials the
  SNP uses to inform members, providers and others
  about their CM programs may satisfy some of the
  requirements
• Does a SNP have to enroll every member referred
  for CM?
• No. Plans do not have to enroll every member
  referral, but must consider them
• Health information line referral is not required
  for Medicare, do the SNPs have to have this?
• This factor may be scored NA, but if a SNP has
  an HIL, it must accept referrals

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SNP 1 Element B Examples

• Documentation may include
• Identify certain disease state or conditions,
  certain diagnoses or critical events, and
  indicators of the members ability to manage
  his/her condition and pharmacy or lab values that
  confirm a lack of control that automatically make
  the member eligible for case management
• A description which indicates how the
  organization uses the data sources to confirm
  case management referrals are appropriate for
• Members need for long-term monitoring,
  interventions and support
• Members showing a lack of progress with
  stabilizing his/her condition, the inability to
  manage co-morbidities or declines in health
  status

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SNP 1 Element C

• Case Management Systems
• Conduct assessment and management
• evidence-based clinical guidelines or algorithms
• Scripts or protocols with EBG meet the intent
• Automatic documentation of contacts
• the staff member who made contact
• the date and time when the organization acted on
  the case or interacted with the member
• Automated prompts for follow-up, as required by
  the case management plan

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SNP 1 Element C FAQs

• What type of guidelines should be used for Factor
  1?
• Any evidence-based guidelines are acceptable.
  They must provide documentation of clinical
  evidence used to develop the CM system.
• Scripts or other prompts that have an evidence
  base satisfy this factor
• What about frail members or those where there are
  not available or appropriate guidelines?
• For frail members, plans are not required to use
  guidelines that may not be appropriate

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SNP 1 Element C Examples

• Documentation may include
• For Factor 1
• Online scripts and checklists that allow case
  managers to obtain information on interventions
  in evidence-based care plan by physician, any
  care gaps or mitigating circumstances and assess
  the members compliance with the care plan
• Screen shots supplemented with policies or
  descriptions that specify how the case manager
  performs the assessment activities
• Flow charts that include descriptions of
  assessment process activities and the clinical
  evidence used in the process
• For Factors 2 and 3
• Screen shots from electronic case management
  systems that capture the date, time, user ID,
  action by the case manager along with reminders
  and follow-up due dates policies or usage
  instructions accompany these screen shots

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SNP 1 Element D

• Frequency of Member Identification
• Systematically identify members
• At least monthly
• given the dynamic nature of clinical data, an
  organization that uses these data with greater
  frequency has the greatest opportunity to
  identify members who may benefit most from CM
  programs

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SNP 1 Element D FAQs

• What if a plan automatically enrolls all members
  in CM?
• Plans that auto-enroll all members in CM will
  receive 100 for this element

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SNP 1 Element E

• Providing Members With Information How does the
  SNP get information to members
• How to use the services
• How members become eligible to participate
• How to opt in or opt out

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SNP 1 Element E

• What type of data sources is NCQA looking for?
• Plans can use the scripts and program information
  they provide to members to satisfy the
  requirements
• In some states, SNPs are required to provide CM
  to all members, so opt out should not apply
• Factor 3 is NA if the organization is required
  by states or others to provide case management to
  all members

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SNP 1 Element F

• Case Management Process
• Members right to decline participation or
  disenroll
• Health status
• Clinical history and meds
• Activities of daily living
• Mental health status and cognitive function
• Life planning activities
• Cultural and linguistic needs, preferences or
  limitations

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SNP 1 Element F (cont. )

• Case Management Process Requires
• Caregiver resources
• Available benefits
• Case management plan with long- and short-term
  goals
• Barriers
• Follow-up schedule
• Self-management plan (needs to
• be documented)
• Assessing progress

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SNP 1 Element F FAQs

• Can Plans use screen shots from a computerized
  questionnaire to show compliance with this
  element?
• Yes, provided the screen shots display the fields
  with the relevant questions related to the
  factors

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SNP 1 Element F Examples

• Evidence that addresses requirements in each of
  the fourteen factors may consist of
• Policies and procedures which delineate the case
  managers actions and documentation requirements
  during the initial assessment, care plan
  implementation and follow-up activities. These
  policies must be supplemented with
  questionnaires, or call scripts the call managers
  uses for care plan implementation, evaluation and
  follow-up activities.
• Screen shots supplemented by instructions or
  policies and documentation guidelines the case
  manager uses during initial assessment, care plan
  implementation, evaluation and follow-up
  activities.
• Printer friendly versions from an electronic case
  management system that detail timing, status,
  results of initial assessment, care plan
  implementation, evaluation and follow-up
  activities the case manager performs.

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SNP 1 Element F (cont.)

• Key items in the factors
• Health status
• Clinical history
• ADLs
• Mental health status
• Life planning
• Cultural and linguistic needs
• Caregiver resources
• Benefits
• Case management plan and goals
• Barriers
• Follow-up schedule
• Self-management plan
• Assessing progress

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SNP 1 Element G

• Informing and Educating Practitioners
• Instructions on how to use CM services
• How the organization works with a practitioners
  patients in the program
• must have a documented process for providing
  practitioners with information that includes
  instructions on how to use the CM services

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SNP 1 Element G FAQs

• Does the plan have to do all of the items in the
  examples section to get credit?
• The examples are meant to provide guidance and
  are not all-inclusive

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SNP 2 Improving Member Satisfaction
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SNP 2 Element A

• Assessment of Member Satisfaction
• Identify the appropriate population
• Draw appropriate samples from the affected
  population, if a sample is used
• Collect valid data

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SNP 2 Element A FAQs

• Does the member satisfaction apply only to the
  SNPs case management program?
• SNPs must assess member satisfaction across its
  entire operations, not just its CM program.
• Can SNPs use self-reported data from members,
  such as member satisfaction with practitioner
  availability or other existing surveys?
• SNPs may use self-reported data to satisfy this
  element.
• IF SNPs have CAHPS data, that would satisfy this
  element in place of analyzing complaints and
  appeals

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SNP 2 Element B

• Opportunities for Improvement
• Plans must review their data and determine how
  best to improve
• Identify opportunities

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SNP 2 Element B FAQs

• What if no opportunities for improvement are
  identified?
• If no opportunities are identified in the SNPs
  analysis, and NCQA surveyors agree with this
  conclusion, the element is scored NA.
• Do SNPs have to show improvement based on the
  opportunities identified?
• For phase one (2008), plans are not required to
  demonstrate they have taken action on the
  identified opportunities
• NCQA anticipates required actions to be taken in
  for review in subsequent years

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SNP 3 Clinical Quality Improvements
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SNP 3 Element A

• The organization measures quality of clinical
  care to improve that care
• Organization selects 3 measures to assess
  performance and identify clinical improvements
  that are likely to have an impact on the
  membership
• 1st step in a phased approachShow areas for
  improvement
• Next year and beyondadd steps to require plans
  to demonstrate actual clinical improvements

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SNP 3 Element A FAQs

• Can a SNP use HEDIS measures to identify relevant
  clinical improvements?
• SNPs may use HEDIS measures to satisfy this
  element
• Do SNPs have to show actual clinical improvements
  for this phase?
• Plans must show the areas they have identified
  for improvement, but are not required to
  demonstrate clinical improvements
• NCQA anticipates adding steps to this measure to
  require plans to demonstrate actual clinical
  improvements in later phases of the program.

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Additional Resources
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Training Education

• Five training topic areas, focus is on content
  and data submission
• Introduction to NCQA HEDIS
• SNP Subset of HEDIS Measures
• Interactive Data Submission System (IDSS)
• Structure Process Measures
• Interactive Survey System (ISS)

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NCQA Policy Clarification Support (PCS)

• Web address
• http//app04.ncqa.org/pcs/web/asp/TIL_ClientLogin
  .asp
• Link from SNP Web page
• www.ncqa.org/snp.aspx

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PCS (contd)

• Under Standard Categories/HEDIS Domain, select
  one of the following options
• SNP General Reporting Guidance
• SNP HEDIS
• SNP Structure Process Measures
• Menu options under Standard/Measures
• If SNP General Reporting Guidance was
  selected
• Not Applicable

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PCS (contd)

• Menu options under Standard/Measures
• If SNP HEDIS was selected
• (COL) Colorectal Cancer Screening
• (GSO) Glaucoma Screening in Older Adults
• (SPR) Use of Spirometry Testing in the Assessment
  and Diagnosis of COPD
• (PCE) Pharmacotherapy of COPD Exacerbation
• (CBP) Controlling High Blood Pressure
• (PBH) Persistence of Beta Blocker Treatment After
  a Heart Attack
• (OMW) Osteoporosis Management in Older Women
• (AMM) Antidepressant Medication Management
• (FUH) Follow-Up After Hospitalization for Mental
  Illness
• (MPM) Annual Monitoring for Patients on
  Persistent Medications
• (DDE) Potentially Harmful Drug-Disease
  Interactions
• (DAE) Use of High Risk Medication in the Elderly
• (BCR) Board Certification
• Other

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PCS (contd)

• Menu options under Standard/Measures
• If SNP Structure Process was selected
• SNP 1 Complex Case Management
• SNP 2 Improving Member Satisfaction
• SNP 3 Clinical Quality Improvements
• Other

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Contacts

• Brett KayDirector, SNP Assessment202-955-1722k
  ay_at_ncqa.orgCasandra MonroeAssistant Director,
  SNP Assessment202-955-5136monroe_at_ncqa.org

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• Questions?