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SNP Training Topic 3: Structure

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Describe the SNP evaluation project NCQA is executing on behalf of CMS ... records or files, such as denial, appeal or credentialing flies that show direct ... – PowerPoint PPT presentation

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Title: SNP Training Topic 3: Structure


1
SNP Training Topic 3 Structure Process
Measures
  • March 27, April 1, 2, 4, 2008

2
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.

3
Goal for SNP Evaluation Program
  • Robust and comprehensive assessment strategy
  • Applies to all SNPs
  • Responsive to the special in SNP
  • Can be implemented soon

4
Three-Year Strategy
5
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

6
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

7
SNP Structure and Process Measures Brett Kay,
Director, Special Needs Plan AssessmentAisha
Pittman, Senior Health Care Analyst
8
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)

9
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

10
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.

11
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

12
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.

13
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

14
SNP 1 Complex Case Management
15
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

16
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.

17
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.

18
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.

19
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

20
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

21
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

22
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

23
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

24
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

25
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

26
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

27
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

28
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

29
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

30
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

31
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

32
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.

33
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

34
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

35
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

36
SNP 2 Improving Member Satisfaction
37
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

38
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

39
SNP 2 Element B
  • Opportunities for Improvement
  • Plans must review their data and determine how
    best to improve
  • Identify opportunities

40
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

41
SNP 3 Clinical Quality Improvements
42
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

43
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.

44
Additional Resources
45
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)

46
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

47
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

48
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

49
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

50
Contacts
  • Brett KayDirector, SNP Assessment202-955-1722k
    ay_at_ncqa.orgCasandra MonroeAssistant Director,
    SNP Assessment202-955-5136monroe_at_ncqa.org

51
  • Questions?
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