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SNP Training Topic 3: Structure


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Title: SNP Training Topic 3: Structure

SNP Training Topic 3 Structure Process
Measures 1 through 3
  • March 12, 19, 25 and April 23, 2009

Objective of SP Measures Training
  • Describe the SNP assessment 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.

Objectives of SNP Assessment Program
  • Develop a robust and comprehensive assessment
  • Evaluate the quality of care SNPs provide
  • Evaluate how SNPs address the special needs of
    their beneficiaries
  • Provide data to CMS to allow plan-plan and
    year-year comparisons

SNP Assessment How did we get here?
  • Existing contract with CMS to develop measures
    focusing on vulnerable elderly
  • Revised contract to address SNP assessment
  • 1st yearrapid turnaround, adapted existing NCQA
    measures and processes from voluntary
    Accreditation programs
  • 2nd yearfocus on SNP-specific measures
  • 3rd yearRefine measures identify new
    SNP-specific measures, where appropriate

Three-Year Strategy
Who Reports
  • HEDIS measures
  • All SNP plan benefit packages with 30 members as
    of February 2008 Comprehensive Report (CMS
  • SP measures
  • All SNP plan benefit packages
  • Plans with no enrollment exempt from certain

What to Report
  • SP measures
  • Cohort IAll SNPs operational as of January 1,
    2007 and renewed in 2009.
  • SP measures 4-7 (SNP 2C 3B)
  • Cohort IIAll SNPs operational as of January 1,
    2008 and renewed in 2009
  • All SP measures (SNP 1-6)
  • Do not report SNP 7 (SNP 2C 3B)

Project Time Line Phase II
  • March 4 - Release final SP measures
  • March 30 - Release ISS Data Collection Tool
  • S P Measures
  • April - Release IDSS Data Collection Tool
  • HEDIS Measures
  • June 30 - HEDIS submissions and SP measures
    submissions due to NCQA
  • October 30 - NCQA delivers SNP Assessment Report
    to CMS

SNP Structure and Process Measures Brett Kay,
Director, SNP Assessment Casandra Monroe,
Assistant Director, SNP Assessment
SNP Assessment Process
  • Phased Approach
  • Defining and assessing desirable structural
  • Assessing processes
  • Assessing outcomes
  • Two main components
  • HEDIS Measures-focus on clinical performance
  • Structure Process measures-focus on structural
    characteristics and systems

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

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

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

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 does not require file review
    for phase two.

Components of an SP Measure
  • Scope of Review The extent of the organizations
    services evaluated during an NCQA survey.
  • 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

SNP 1 Complex Case Management
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

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
  • Note NCQA looking to collect information on
    eligibility criteria used by plans for CM and
    data on of members enrolled in CM.

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 and maintain all members
    in CM can provide evidence of this and receive
    100 for this element
  • What if CCM is part of larger DM program?
  • SNPs must have a CCM program. This program may be
    part of a broader DM program, but the SNP must
    demonstrate that it meets the requirements for

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.

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 (must specify what these are)

SNP 1 Element B FAQs
  • What type of information is NCQA looking for?
  • Documented processes, reports or materials that
    demonstrate the SNP allows referrals from
    multiple sources
  • 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

SNP 1 Element B Examples
  • Documentation may include
  • A policy for the case management referral process
    that identifies which persons or entities refer
    members for services
  • 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
  • A flowchart detailing the steps of the case
    management process and persons used as referral
    resources within it

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

SNP 1 Element C FAQs
  • What type of guidelines should be used for Factor
  • 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

SNP 1 Element C
  • Documentation for Factor 1 may include
  • 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
  • Documentation for Factors 2 and 3 must include
  • 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

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

SNP 1 Element D FAQs
  • What if a plan automatically enrolls all members
    in CM?
  • Plans that auto-enroll and maintain all members
    in CM can receive 100 for this element (if they
    provide appropriate documentation) --also applies
    to SNP 1A, 1B and 1E Factor 2
  • What type of information is NCQA looking for?
  • Documented processes or reports that demonstrate
    the frequency with which SNPs systematically
    identify eligible members for CM

SNP 1 Element E
  • Providing Members With Information Does the SNP
    give members written and verbal information on
  • How to use the services
  • How members become eligible to participate
  • How to opt in or opt out

SNP 1 Element E
  • What type of data sources is NCQA looking for?
  • To demonstrate performance on this element, the
    SNP must provide
  • Documented processes that describe the process
    for notifying members and
  • Materials provided to members
  • 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

SNP 1 Element F
  • Case Management Process
  • Members right to decline participation or
  • 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

SNP 1 Element F (cont. …)
  • Case Management Process Requires
  • Caregiver resources
  • Available benefits
  • Case management plan with long- and short-term
  • Barriers
  • Follow-up schedule
  • Self-management plan (needs to
  • be documented)
  • Assessing progress

SNP 1 Element F FAQs
  • Can Plans use screen shots from a computerized
    questionnaire or case management system to show
    compliance with this element?
  • Yes, provided the screen shots display the fields
    with the relevant questions related to the

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
  • 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.

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

SNP 1 Element G FAQs
  • What type of information is NCQA looking for?
  • To demonstrate performance on this element, the
    organization must provide
  • Documented processes that describe its process
    for notifying practitioners and
  • Materials provided to practitioners
  • Examples of materials include
  • Provider manuals
  • Training brochures
  • information on Organizations Website

SNP 2 Improving Member Satisfaction
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
  • Plans with no enrollment as of the start of
    the look-back period are exempt from this element

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
  • SNPs can use CAHPS data they have analyzed to
    satisfy this element in place of analyzing
    complaints and appeals

SNP 2 Element A FAQs
  • If we do not pull a sample and analyze member
    satisfaction data for our entire SNP population
    will NCQA score Factor 2 NA?
  • NCQA scores Factor 2 Yes when an organization
    analyzes member satisfaction data for its entire
    SNP population
  • How recent must the data be for this element?
  • Data must be collected no more than 12 months
    prior to the look back period

SNP 2 Element B
  • Opportunities for Improvement
  • Plans must review their data and determine how
    best to improve
  • Identify opportunities
  • Plans with no enrollment as of the start
    of the look-back period are exempt from this

SNP 2 Element B FAQs
  • What if no opportunities for improvement are
  • 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?
  • Plans undergoing the SNP Evaluation for the first
    time in 2009 are not required to demonstrate they
    have taken action on the identified opportunities
  • Plans that completed the SNP Evaluation in 2008
    must provide evidence of actions taken and a plan
    to evaluate its actions

SNP 3 Clinical Quality Improvements
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
  • Plans must demonstrate that each of the 3
    clinical issues is relevant to its membership.
  • Plans with no enrollment as of the start
    of the look-back period are exempt from this

SNP 3 Element A FAQs
  • Can a SNP use HEDIS measures to identify relevant
    clinical improvements?
  • SNPs may use HEDIS measures to satisfy this
  • Do SNPs have to show actual clinical improvements
    for this phase?
  • Plans undergoing the SNP Evaluation for the first
    time in 2009 are not required to identify
    opportunities or demonstrate they have taken
    action to show improvement
  • Plans that completed the SNP Evaluation in 2008
    must demonstrate they identified opportunities
    and decided which ones to pursue.

SNP 3 Element A FAQs
  • Can a SNP submit service-oriented performance
    measures and meet SNP 3A?
  • No, measures for this element must involve
    improvements in the quality of clinical care
  • Should a SNP use a particular format for its
  • The ISS Survey tool contains a supplemental
    worksheet plans can use to demonstrate

General FAQs
  • Could you clarify the look-back period and
    whether a SNP must develop or review all of its
    documentation within that this timeframe?
  • The look-back period is the three-month period
    prior to survey submissionMarch 31, 2009 to June
    30, 2009. All documentation must be current as
    of the look-back period but it could have been
    developed before that time.
  • For evidence consisting of a policy, an
    organization that did not have one in place can
    develop and incorporate it into its operations
    during the look-back period.

General FAQs
  • We contract with other entities (medical groups)
    to perform a number of the functions assessed by
    the Structure and Process measures. How should
    we demonstrate performance with these
  • Your organization needs to provide the
    appropriate evidence from these contracted
    entities to documenting their performance. In
    addition you should discuss the details of this
    documentation with a member of the SNP Team.

Additional Resources
Additional Resources
  • NCQA SNP Web page
  • FAQs (HEDIS)
  • Training descriptions schedule
  • SP measures
  • NCQA Policy Clarification Support (PCS)
  • http//
  • HEDIS Audit information
  • http//

Policy Clarification Support (PCS)
  • PCS Web address
  • http//
  • Link for SNP Web page

Policy Clarification Support (PCS)
  • Under Standard Categories/HEDIS Domain, select
    one of the following options
  • SNP General Reporting Guidance
  • SNP Structure Process Measures
  • Menu options under Standard/Measures
  • If SNP General Reporting Guidance was
  • Not Applicable

Policy Clarification Support (PCS)
  • Menu options under Standard/Measures
  • If SNP HEDIS was selected
  • (COL) Colorectal Cancer Screening
  • (GSO) Glaucoma Screening in Older Adults
  • (COA) Care for Older Adults
  • (SPR) Use of Spirometry Testing in the Assessment
    Diagnosis of COPD
  • (PCE) Pharmacotherapy Management of COPD
  • (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
  • (MPM) Annual Monitoring for Patients on
    Persistent Medications
  • (DDE) Potentially Harmful Drug-Disease
  • (DAE) Use of High Risk Medication in the Elderly
  • (MRP) Medication Reconciliation Post-Discharge
  • (BCR) Board Certification
  • (HOS) Medicare Health Outcomes Survey
  • Other

Policy Clarification Support (PCS)
  • 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
  • SNP 4 Care Transitions
  • SNP 5 Institutional Relationship with Facilities
  • SNP 6 Coordination of Medicare and Medicaid
  • Other

Additional SNP Trainings
  • SNP Subset of HEDIS Measures
  • March 3rd 1130 100
  • March 11th 1130 100
  • March 16th 100 - 230
  • March 26th 100 - 230
  • April 1st 1230 - 200
  • Structure and Process Measures (SP 1-3)
  • March 12th 100 230
  • March 19th 100 - 230
  • March 25th 1230 - 200
  • April 23rd 200 330

Additional SNP Seminars
  • Structure and Process Measures (SP 4-6)
  • March 17th 200 - 330
  • March 24th 200 - 330
  • March 31st 200 - 330
  • April 2nd 1230 200
  • April 7th 200 - 330
  • April 15th 100 230
  • Interactive Survey System (ISS)
  • April 8th 100 230
  • April 14th 100 - 230
  • April 17th 100 230
  • April 21st 100 - 230
  • April 28th 100 230
  • May 7th 100 230

  • Brett Kay Director, SNP Assessment 202-955-1722 k Casandra Monroe Assistant Director,
    SNP Assessment 202-955-5136

  • Questions?