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Special Needs Plan Model of Care Training 2015-2017 w
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Overview • Purpose and Use of a Model of Care (MOC) • Key Components of the MOC • Goals of the MOC • AgeWell New York member populations • Interdisciplinary Care Team (IDT) • Health Risk Assessments (HRAs) and Risk Stratification • Person-Centered Service Care Plan (PCSP) • Measurable Goals • Provider Roles and Responsibilities • Communication Network • Performance and Health Outcomes Measurement • Consumer Self Direction
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Purpose and Use of a Model of Care (MOC) • The Model of Care is the guidepost for the implementation
and delivery of care management and health services to enrollees.
• The MOC represents a comprehensive program for person centered care planning and coordination that addresses the entire array of acute care, primary care, behavioral health, specialist services, and long term care services and supports that enrollees need.
• For enrollees, the MOC is used to improve: access to needed services, affordable and cost effective care, transitions across health care settings and providers, access to preventive health services, and health outcomes.
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Key Components of the Model of Care
• Understanding of the target population • Measurable goals • Staff structure and care management roles • Interdisciplinary care team (IDT) • Provider network having specialized expertise and using
clinical guidelines • MOC training for staff and provider network • Health risk assessments (HRA) • Person-Centered Service Care Plan (PSCP) • Communication network • Care management for the most vulnerable subpopulations • Performance and health outcomes measurement • Use of self directed services
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Model of Care Goals • Model of Care goals defined by CMS:
• Improve access to essential services such as medical, mental health and social services
• Improve access to affordable care • Improve coordination of care through an identified point of
contact • Improve seamless transitions of care across healthcare settings,
providers and health services • Improve access to preventive health services • Assure appropriate utilization of services • Improve beneficiary health
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Goals for Model of Care
Improving health outcomes of
Members
Coordinating care with Primary Care
Physician or Medical Home
Supporting seamless transitions across
health care settings and providers
Ensuring access to preventive services
Ensuring access to essential services and
affordable care
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AgeWell New York member populations • Dual eligibility under Medicare and Medicaid public insurance
programs. • In New York, duals represent about 25% of Medicare population and
about 15% of Medicaid population. • In general, dual eligibles are a high cost, vulnerable population with
complex health needs. By definition, all are low income, and elderly or disabled or both.
• Relative to other Medicare beneficiaries, duals are more likely to have at least three limitations in activities of daily living, have more chronic conditions and/or report poor health status.
• Dual eligibles are more likely to suffer from cognitive impairment and mental disorders, and have higher rates of diabetes, pulmonary disease, stroke and Alzheimer’s disease than nondual eligibles.
• Over 70% are over 75 years of age, over 65% are female, and top diagnoses include hypertension, osteoarthritis, diabetes and mental disorders. About half of the members live with family and the other half lives alone.
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Staff Structure & Care Management Roles • The structure of the Model of Care is comprised of employed
and contracted staff the perform administrative, clinical and oversight functions.
• Examples of Administrative functions: • Enrollment processing, eligibility verification, reporting and
member reconciliation • Adjudication of claims, third party recovery, authorization
administration and data collection • Member and provider customer service • Management of contract & product support, regulatory
compliance, internal business area support
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Staff Structure & Care Management Roles • Examples of Clinical Functions:
• Care Management, including inpatient, and transitional settings • Assessment of members needs • Data analysis and evaluation of program goals
• Examples of Administrative & Clinical Oversight • Professional staff credentialing • Utilization management including prior authorization &
notification • Develop evidence based criteria by reviewing available evidence,
current standards of practice & existing coverage positions as defined by laws, rules and regulations.
• Investigate and conduct reviews to confirm corporate compliance program
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Interdisciplinary Team (IDT)
• Each member is assigned to an IDT, which has the primary purpose of coordinating the delivery of services and benefits to address member specific needs
• Members of the IDT are determined by analysis of the members initial health risk assessment and subsequent assessments.
• Typically, IDT composition includes the assigned Care Manager, Primary Care Physician, specialists involved in the care of the members, home and community based providers, the member and caregivers/family.
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Interdisciplinary Team (IDT) • Additional IDT members may include pharmacist, restorative
therapists, nutritionist, health educator, other disease management specialists.
• Care Management team assumes critical role in coordinating and communicating with the IDT and the member.
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Health Risk Assessments (HRAs)
• Use of standardized, comprehensive approach to collecting, analyzing and communicating health risk assessment information. Identify current and future health risks.
• Combination of various assessments, including NYS required UAS-NY, that focus on medical, psychosocial, cognitive and functional needs and disabilities of members.
• AgeWell New York assessments include falls risk, diabetic knowledge, Braden Scale (mental health), home environment and emergency preparedness, respiratory and cardiac as examples.
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Health Risk Assessments (HRAs) • HRAs performed on initial assessment and reassessments
include full medication review. Results discussed with member’s Primary Care Physician to avoid poly-pharmacy, drug-to-drug interactions, decreased potentiated side effects, sub-therapeutic dosages, and actual or perceived allergies or side effects.
• HRA reviews allow for prioritization of problems and interventions within the plan of care and identification of gaps in continuity of care guided in evidence-based practices.
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Risk Stratification: Identifying Vulnerable Members
Risk Level Description High risk • Multiple chronic conditions such as CHF, diabetes, hypertension and
psychological needs, difficulty controlling symptoms • Recent visits to Emergency Department • Diagnosis of dementia or other cognitive impairments, lacking or
limited support systems in the community
Moderate risk • Two or more chronic conditions • History of behavioral health, psychosocial needs • Decreased or diminished compliance with medications and
therapeutic regimen • Increased functional deficits, high need for ADL assistance
Low risk • Well managed chronic disease and symptoms • Can live in the community with adequate long term services and
supports • Compliance with medications and therapeutic regimen. • Minimal ADL support needs
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Person-Centered Service Care Plan (PCSP) • The PCSP is a comprehensive, person centered plan of care
describing in detail the member’s health and medical needs, personal goals, and care management and coordination of services across the continuum of care.
• The Interdisciplinary Team (IDT), led by the Care Manager, develops the ICP with the involvement of the member and/or family/caregivers.
• The Care Manager maintains monthly communication with the members to address any issues or questions about the PCSP and/or services and benefits.
• The PCSP identifies and reflects the member’s unique needs and the services and care needed to meet those needs. Special services and benefits are included in the ICP according to the needs identified through the Health Risk Assessments (HRAs)
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Person-Centered Service Care Plan (PCSP) • The outcomes of the are measured and documented in the
care plan. Member preferences for care are documented in the PCSP.
• The PCSP addresses and documents add-on benefits and services for vulnerable populations such as those with Alzheimer’s Disease (AD) dementia, drug abusers, those with frequent falls, those using 9 or more medications, unmanaged chronic diseases, end-of-life issues or those without connection to a Primary Care Physician (PCP).
• PCSPs are reviewed and revised by the member assigned Care Manager, in coordination with the member’s PCP, every six months or more frequently as called for when there has been a change in a member’s condition or other triggering events.
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Measurable Goals • Improving access to essential services by meeting or exceeding standards for
access to routine care, non-urgent sick care, wellness care, mental health services and emergency follow-up services, as examples.
• Improving access to affordable care by encouraging use of network providers, and addressing issues arising out of grievances and action appeals.
• Improving coordination of care by an identified point of contact, i.e., Care Manager, assisting the member in navigation of health system and communicating routinely with the IDT.
• Improving seamless transitions of care by recognizing complex health needs, and transmitting health information on a timey basis for a smooth transition across settings, providers and post-discharge from an inpatient or residential facility.
• Improving access to preventive health services by promoting and educating members about value of preventive and wellness services.
• Assuring appropriate utilization of services by avoiding over use and under use of services through clinical coverage decisions based on available evidence-based guidelines.
• Improving members health outcomes by a formal process to monitor and evaluate the necessity, appropriateness, efficiency, effectiveness, and safety of health and medical services ordered for and provided to members.
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Communications Network Contact Target Communication Methods and Forms
Members Written correspondence/phone calls documented in the care management system Face-to-face meetings and 24/7 Call Line Website Member Portal Quarterly Member Newsletters Multilingual staff and translational Services
Providers Provider Manual and Contract Phone calls and face-to-face meetings Website Provider Portal Written correspondence Webex trainings Quarterly Provider Newsletter Corporate Compliance Hotline Fax/Email
Regulators Written correspondence Conference calls Reporting – monthly, quarterly and on an annual basis Face-to-face meetings Participation in advocacy/trade associations Secure electronic upload/download of crucial plan specific information
General Public Website Outreach and community relations activities to promote market awareness Media and print advertising including brochures Newsletters Multilingual staff and translational services
AgeWell New York staff Employee portal on website Written correspondence Case Conferences ICT standing and ad hoc committees QAPI Committee Weekly/Monthly staff meetings Corporate Compliance Hotline
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Performance and Health Outcomes Measurement • AgeWell’s Model of Care (MOC) uses evidence-based practices
and applies continuous performance oversight to identify opportunities for improvement.
• Evidence-based practices and various industry standards are applied to monitor and measure performance and health outcomes including: HEDIS, utilization management standards, member satisfaction studies, provider surveys, analyses of grievances and appeals, claims data, high cost and utilization outlier analyses, poly-pharmacy, and disease-specific standards and practices, as examples.
• Performance and Health Outcomes measurement is applied for the improvement of the MOC, and changes are communicated to members, network providers, IDTs, community partners and internal staff.
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AgeWell New York Contact Information
• Website: www.agewellnewyork.com • General Information and Member Services: 1 866 586-8044 • Corporate office: 1991 Marcus Avenue, Suite M201 Lake Success, New York 11042 • Claims Services: AgeWell New York c/o RelayHealth 1564 Northeast Expressway Mail Stop HQ-2361 Atlanta, Georgia 30329 1 866 775-8860 email: [email protected]
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