scan health plan model of care (moc) training · rn: scan health plan (scan) is a provider approved...

SCAN Health Plan confidential and proprietary information. © 2019 SCAN Health Plan. All rights reserved.

Special Needs

Plan (SNP) Model

of Care Training May 30, 2019

SCAN Health Plan confidential and proprietary information. © 2019 SCAN Health Plan. All rights reserved.2

Lisa Roth, VP Care Coordination

• [email protected]

Janelle Howe , Director Clinical Care


Maureen Mello, Senior Project Manager


Lisa Desai, Manager Care Coordination


Henry Argueta, Personal Assistance Line Specialist


Adalinda Gutierrez RN, BSN, PHN, Network Compliance Mgr – Clinical


Kim Kochan RN, VP Care Management – AppleCare

Gabriela Segovia, Director Ambulatory Care Management – Epic/

Beaver

Presenters

mailto:[email protected]







Accreditation Statement

RN: SCAN Health Plan (SCAN) is a provider approved by the

California Board of Registered Nursing (Provider #CEP-13453).

This activity has been approved for up to 1.5 contact hour(s).

BBS: Course meets the qualifications for 1.5 hours of continuing

education credit for LMFTs, LCSWs, LPCCs, and/or LEPs as

required by the California Board of Behavioral Sciences. SCAN

Health Plan is a CAMFT-approved continuing education provider.

Provider No. 127226


Questions from the Audience


First 60 min of the presentation : • SCAN’s Special Needs Plan (SNP) Model of Care (MOC)Training

– This applies to all Medical Groups delegated to provide care for

below SNP types:

Chronic Special Needs Plan (C-SNP) – Balance, heart First,

VillageHealth

Dual Special Needs Plan (D-SNP) - Connections, Connections

at Home

Institutional Special Needs Plan (I-SNP) – Healthy at Home

Second 30 min of the presentation :• SCAN’s Initial Health Assessment (IHA)/ Staying Healthy

Assessment (SHA) Training

– This applies to all Medical Groups delegated to provide care for the

below SNP type:

D-SNP – Connections, Connections at home

Important Note


Learning Objectives

Objective 1

Objective 2

Objective

3

Identify the 4

elements of model

of care

Demonstrate Audit &

oversight preparedness

Explain your

requirements as a

SNP provider


The 4 elements of SNP model of care

SNP Population

Care Coordination

Provider Network

Quality Measurement

& Performance

Special Needs Plans:

- Chronic SNP (C-SNP)

- Fully Integrated Dual

Eligible SNP (FIDE –SNP)

- Institutional SNP (I-SNP)

Care Coordination:

- Health Risk Assessment (HRA)

- Individualized Care Plan (ICP)

- Interdisciplinary Care Team (ICT)

- Care Transitions (CT)

Staff/providers deliver

care to SNP

members must

complete SNP MOC

training annually

- Measures are evaluated on

an annual basis

- SNP model of care program

evaluation process

- Quality Improvement Plan

Note : Please refer to appendix for more information on each of these elements.

Appendix slides I -VIII


Journey of a Special Needs Plan Member

Member becomes a

SNP member

SCAN Care Coordinator onboard

the memberConducts the HRA and ICP

• HRA - Health Risk

Assessment

• ICP – Individualized Care

Plan

Documents placed on SNP

sftp• Copy of the Health Risk

Assessment (HRA)

• Copy of the Individualized Care

Plan (ICP)

• Trigger Report with identified

triggers from HRA responses

Case Management

activities for triggered

SNP members begin

/and or Care Transitions

activities (Based on the

delegation status)


Appendix slides V-VIII


Journey Continues….(SCAN)

Member becomes a

SNP member

SCAN Care Coordinator onboard

the member

Conducts the Health

Risk Assessment, Care

Plan

Documents placed on SNP sftp

• Copy of the Health Risk

Assessment (HRA)

• Copy of the Individualized Care

Plan (ICP)

• Trigger Report with identified

triggers from HRA responses




Journey Continues….(SCAN Medical Group)



Pick up documents

placed on SNP sftp

Case Management

activities for triggered

SNP members begin /and

or Care Transitions

activities (Based on the

delegation status)


Journey Continues…. SNP Care Management

Obtain SCAN

Trigger Report

Member

Assignment

Assessment and

Problem/Opportunity

Identification

Care Plan

Development from

HRA/Member/Medical

Review

Member agreement

with Care Plan

Interdisciplinary

Care Team

Care Plan

Implementation and

Coordination of ICT

Re-evaluation of

Care Plan and

ongoing Follow-up


Journey Continues…. SNP Care Transitions

1

Notification of

member admissionConduct Member

outreach Notify Primary Care

Physician of the

discharge

Conduct &

document member

coaching

Care Plan is transferred between

setting before, during and after a

transition of care

2 3

4

5

Update the Care Plan

& share it with

members of the ICT

6Conduct

Interdisciplinary

Care Team

78

Submit CT Logs on

a quarterly basis


Polling Questions

When should an individualized care plan be written or revised?

a) After completing the HRA with the member

b) When discussing the health care concerns with the patient

c) Following discharge from a facility

d) If the patient raises health concerns

e) All of the above


Polling Questions

What is the minimum composition of an ICT?

a) Case Manager Assigned to member, Care Coordinator

b) Case Manager Assigned to member, Care Coordinator, Medical expert

c) Case Manager Assigned to member, Care Coordinator, Medical expert,

Member/caregiver

d) Medical expert, Member/caregiver

e) None of the above


Polling Questions

True/ False

Documentation should indicate members contacted within 5

business days post discharge from one setting to another


Audit & oversight preparedness


Audit & oversight preparedness

Ongoing Delegation Oversight

Audits

- Chart review

- Policy & Procedure Review

- Corrective Action Plans

(CAPs)

CMS Audit Preparedness

- Notification

- Chart requests (Case

Management documentation)

- End to End Case walkthroughs

(live webinars)


Questions

Thank you

SCAN Health Plan confidential and proprietary information. © 2019 SCAN Health Plan. All rights reserved.

Initial Health

Assessment/

Staying Healthy

Assessment

Annual Provider TrainingMay/June 2019

Lisa Amin Desai

Manager, Care Coordination


Regulatory Requirements

Medicare

• Initial Assessment within 90

days of enrollment (Welcome

to Medicare)

• Annual Assessment (Annual

Wellness Visit or AWV) – once

per year

21

Medi-Cal

• Initial Health Assessment

(IHA) within 120 days of

enrollment

• Must use Staying Healthy

Assessment (SHA) Form

(DHCS approved form)

• Annual Assessment – within

365 days of previous

assessment

* SCAN Policy is for IHA/SHA to be completed within 90 days of

enrollment.


Regulatory Requirements- Specific for Medi-Medi Members

22

Initial Health Assessment

• Comprehensive Exam with PCP

• Documentation of all areas assessed

• IHA completed within 90 days of enrollment

Staying Healthy

Assessment (SHA)

• DHCS Approved Form

• Included as part of Medical Record

• Note if member declines to complete

Initial or Annual or

Preventative Visit Code

• Appropriate coding for initial and annual visits

• Code list included with IHA ASAP report

DHCS requirement to complete Initial Health Assessment

(IHA)/Staying Healthy Assessment (SHA) w/in 120 days of enrollment and annually: Title 22, CCR, Section 53851 (b)(1)


Benefits of Comprehensive Assessments

23

Patients

• Increased engagement – connect

behavior to health outcomes

• Building patient condition

awareness

• Greater patient accountability and

improved health literacy

• Increase patient ability to self

manage

Providers

• Comprehensive assessments

help identification of patient

care needs

• More accurate patient coding

• Greater ability to promote

preventative care

• Decreased acute utilization


Who’s Responsible for What – The Delegated Agreement

SCAN

• Educate medical groups on IHA/SHA requirements

• Ensure providers are conducting IHA/SHA and AWV

• Monitor/audit

Contracted Providers/IPAs

• Track patients and outreach to those due/past due for initial and annual wellness visits

• Ask patients to complete the SHA form, develop plan with patient and review annually, must be filed/documented in patient chart/medical record

Provider Organizations

• Train employed and contracted providers on IHA/SHA/AWV requirements

• Monitor IHA/SHA/AWV and support providers to complete

24


Provider Group Expectations

Policies and Procedures around IHA/SHA and AWV expectations for employed and contracted

Providers

• Delineate Provider Group role in monitoring, training and supporting the completion of the

IHA/SHA and AWV

• Initial and Annual Provider Training

Monthly monitoring of completion of IHA/SHA and AWV

• Track using SCAN Provider Portal Report – IHA_ASAP Report (must access by the 15th of every

month)

• Outreach to Providers

• Outreach to Patients

Ensure Provider documentation (patient chart) includes:

• The SHA form

• Risks identified are addressed, including appropriate tests/screenings

• Areas of low risk are documented indicating why corresponding tests/screenings are not needed

25


Partnering with SCAN

26

SCAN calls each new medi-medi

member to educate on IHA/SHA during

welcome call-offers to facilitate IHA appointment

SCAN sends the SHA form to PCP

with cover letter for each new Medi-

Medi requiring IHA and SHA

You can use this PowerPoint training

presentation to train PCPs

Assigned Delegation

Oversight and HCS support point of

contact


Implementation

How do you use new patient forms?

Can the SHA form be added to new patient forms?

How frequently are patient forms updated?

Can the SHA standards be merged with you current protocol?

What are your quality monitoring processes around initial and annual

wellness PCP visits?

Can it be adjusted to meet the Medi-Cal and Medicare guidelines?

How do you promote wellness visits/preventative care with your

employed/contracted physicians?

Can the Medi-Cal and Medicare standards be integrated into your

current process?

27


Polling Question

Per Medicare and Medi-Cal guidelines, when should a comprehensive exam

be completed for a member?

a) Within the first 12 months of enrollment

b) Within the first 90 days of enrollment and once per year after that

c) Whenever the member decides to visit the doctor

d) When the member has an issue

e) After the member is hospitalized


Resources

DHCS fact sheet/FAQ:

http://www.dhcs.ca.gov/formsandpubs/forms/Documents/MMCD_

SHA/GenDocs/SHA_FAQs.pdf

SHA forms:

http://www.dhcs.ca.gov/formsandpubs/forms/pages/stayinghealth

y.aspx

Policy Letter 13-001 (Revised):

http://www.dhcs.ca.gov/formsandpubs/Pages/PolicyLetters.aspx

United States Preventative Services Task Force:

https://www.uspreventiveservicestaskforce.org/BrowseRec/Index

29

http://www.dhcs.ca.gov/formsandpubs/forms/Documents/MMCD_SHA/GenDocs/SHA_FAQs.pdf

http://www.dhcs.ca.gov/formsandpubs/forms/pages/stayinghealthy.aspx

http://www.dhcs.ca.gov/formsandpubs/Pages/PolicyLetters.aspx

https://www.uspreventiveservicestaskforce.org/BrowseRec/Index


Questions

Thank you


Appendix – IHA/SHA

I. Components of a comprehensive assessment

II. How to identify members who need IHA/SHA

III. Preparing for a DHCS audit

32


I. Components of a Comprehensive Assessment

Complete history and physical (includes, but not limited to):

• Present and past illness(es) with hospitalizations, operations, meds

• Physical exam including review of all organ systems

• Height, weight, BMI, BP, cholesterol screening

• Preventative services per USPSTF A and B Guidelines for 65-year

old (age appropriate assessments such as TB screening, clinical

breast exam, allergy, chlamydia, mammogram, pap smear)

Social history

• Current living situation/marital status

• Work history/education level

• Sexual history/use of alcohol, tobacco and drugs

33


I. Components of Comprehensive Assessment

Mental health and status evaluation

Assessment of risk factors- using the Staying Healthy Assessment (SHA)

• REQUIRED for all Dually Enrolled Medi-Cal/Medicare members

• Development of behavioral risk health education – to include assessment

of:

– Nutrition

– Functional status (including ADL/IADLs)

– Physical Activity

– Environmental Safety

– Dental/Oral Health

Diagnoses and plan of care

Clinical Based guidelines as best practice in development of plan of care

34


II. How to identify SCAN members who need

IHA/SHA

SCAN provides list of new members on monthly basis

SCAN provides detailed patient-level data through IHA ASAP Report

• To access the report on the SCAN provider portal:

– Access the SCAN Provider Portal

– Click on SCAN Documents

– Click on Network

– Access the IHA_ASAP folder

Providers are required to make reasonable attempts to contact

members and schedule IHA. SCAN recognizes best practice of

three good-faith attempts. Documented attempts that demonstrate

unsuccessful efforts to contact members to schedule IHA will be

considered evidence in meeting requirement.

35


III. Preparing for the DHCS Audit

36

Medical record request will include

checklist for all required

components

Prepare to show attestations that all PCPs were trained

on the IHA and SHA requirements

Webinar audit will include review of patient’s EMR/ Medical Record-

live in system


I. SCAN’s Mission

II. SNP types and eligibility

III. SNP goals and purpose of a SNP

IV. Division of responsibilities (plan vs. group)

V. Detailed requirements for trigger report, care plan updates,

documentation of ICT, and CT

VI. SNP sftp operations

VII. SCAN SNP resources

VIII. CMS SNP resources

Appendix – SNP MOC


I. SCAN’s Mission

SCAN Health Plan (SCAN) is the nation’s fourth largest not-for-profit

Medicare Advantage (MA) plan, serving over 180,000 members in

California.

SCAN’s mission is to keep seniors healthy and independent. We do

this is by providing comprehensive medical coverage, prescription

benefits, and support services specifically designed to meet the

unique needs of seniors.


II. SNP types and eligibility

• Eligibility verified 30 days post enrollment

• Balance Plan: Diabetes

• Heart First Plan: CHF, Arrhythmia, CAD, PVD, Chronic Venous Thromboembolic Disorder

• VillageHealth Plan: ESRD

Chronic

Special Needs Plan

(C-SNP)

• Eligibility verified monthly

• Designed for members who have both Medicare Part A and Part B, Full Medicaid benefits and FIDE SNP

• Connections and Connections at Home Plan

Fully Integrated Dual

Eligible Special Needs Plan

(FIDE-SNP/D-SNP)

• Eligibility verified by outside vendor

• Meet state criteria for Nursing Facility Level of Care (NFLOC)

• Healthy at Home Plan - Must reside in the community and not a facility (I-SNP is Institutional-Equivalent)

Institutional

Special Needs Plan

(I-SNP)


III. SNP goals and purpose of a SNP

Improve member health outcomes

Ensure appropriate utilization of services for preventative health and chronic conditions

Enhance care transitions across all healthcare settings

Improve coordination of care and ensure appropriate delivery

of services through the alignment of the HRA, ICP and ICT

Improve access and affordability to member healthcare needs


IV. Division of responsibilities – Plan/Group

Enhance care transitions across all healthcare settings

SCAN Health Plan Delegated Medical Group

Diagnosis Verification (C-SNP) Review & Act on Trigger Reports

Health Risk Assessment (HRA) and

Care Plan (Initial & Annual)*

Provide CM, Interdisciplinary Care &

Care Transitions (CT)*

Provide Weekly Trigger ReportsSubmit Care Transitions (CT) Reports

Quarterly*

Provide Tools & ResourcesFor those in Care Management,

Update Care Plan*

* Village Health Responsibility for End State Renal Disease (ESRD)


V. Health Risk Assessment (HRA)

SCAN

SCAN is responsible for the Health Risk Assessment (HRA)

• Conducted within 90 days of enrollment and annually prior to 365 days from last

Contact attempts to members include telephonic outreach, as well as letters that

include paper HRA forms to complete and return by mail

Minimum outreach attempts to member is three, we often make at least five attempts

Other SCAN assessments meet requirement of HRA (NFLOC)

HRA addresses required domains of medical, functional, psychosocial, mental health

and cognition

Screens SNP members for care coordination, complex care management (and long-

term services and supports for D-SNP)


V. Health Risk Assessment (HRA)

Delegated Medical Group Expectation

Delegates required to retrieve HRAs, care plans and trigger reports within 7 calendar days

of posting on SCAN’s SNP sftp site (trigger reports are sent the Monday after assessment)

Delegates are required to do (within 30 calendar days of receiving the trigger report) in the

members’ records:

• Document the date the trigger report was reviewed

• Document clinical review and outreach attempts (min. 3 attempts within 2 weeks)

• Address care management triggers by analyzing findings from HRA and other

assessments and inputs and document the following:

• If unable to reach members or members decline to participate, follow organization

protocol to complete the activities based on information available in the organization’s

system and update the documentation

• Document next steps/plan of care going forward (sent letter, etc.)

• If member not enrolled in care management, reason (failed contact, declined)

• ICT documentation for all SNP members that triggers regardless of level of acuity


V. Individualized Care Plan (ICP)

SCAN

Individualized Care Plan (ICP) is developed following completion of the

initial health risk assessment (HRA) upon the members’ enrollment and

updated with each discharge from a facility or a change in health status

The ICP includes any triggers identified during the HRA process, any

concerns voiced by members during the HRA process and/or specific

concerns members would like to address with their PCP

The ICP is a dynamic document that’s updated at least annually; it may

be changed more frequently if there is a change in the members’ status

The ICP is shared via mail or electronically with members, primary care

physicians and other members of the ICT


V. Individualized Care Plan (ICP)


Identification of measurable goals, including prioritized goals that consider

the members’ and caregivers’ goals, preferences and desired level of

involvement in the care management plan

Measurable goals include the current status, progress to meeting the goal

and the desired outcome

Address all documented triggers with goals on the ICP

Documentation shows review and revision of the ICP as changes in health

status, function and psychosocial needs are identified (does documentation

address the member issues?)

Evidence of communication of ICP and revisions to members and primary

care physicians (was care plan sent to members and primary care

physicians?)

ICT recommendations are documented in the care plan


V. Interdisciplinary Care Team (ICT)


All triggered SNP members and SNP members received thru referral process need to have an

Interdisciplinary Team (ICT) completed regardless of acuity level within 30 days of referral

Minimum ICT composition (collaboration between any of the following):

• CM assigned to member

• Care coordinator (from SCAN)

• Medical expert (primary care physician, specialist, etc.)

• Members/caregivers if available

Interactions and collaborations can occur in person, telephonically or electronically (a formal ICT

meeting not necessary for all)

ICT documentation must include evidence of the following:

• Date of ICT collaboration

• List of all ICT participants (including all recommended providers)

• Interventions/recommendations

• Evidence that copy of care plan was provided to/available to ICT participants and members

Documentation that all ICT participants completed SNP MOC training


V. Care Transitions (CT)


Care Transitions documentation must include:

• Members contacted (or attempts made) within five business days post-

notification of discharge from one setting to another

• Notification to PCP within five business days of discharge

• Ensure follow-up services and appointments are scheduled and performed

within 5 business days of transition

• Care is provided by appropriate persons

• Care plan transferred between settings before, during, after transition of care

• Member coaching occurred

• Members of the ICT and members/caregivers have access to the plan of

care

Submission of care transition logs to SCAN SNP sftp on a quarterly basis:

• SCAN provides oversight to ensure regulatory and compliance

requirements are met


VI. SNP sftp Operations

SNP Report Job ScheduleDay of the Week

Report is Sent

Completed HRA

and Care PlansWeekly Saturdays

Trigger Reports Weekly Mondays

SNP Census Monthly 2nd of Month


VII.SCAN SNP Resources

SCAN Health Plan Website


VIII.CMS SNP Resources

CMS Website

https://www.cms.gov

• Medicare Managed Care Manual Chapter 5

• Medicare Managed Care Manual Chapter 16b

https://www.cms.gov/

1

SNP MOC Training 2019 – FAQ Sheet

1. What are the requirements/expectations for SCAN Trigger Report in terms of outreach, ICP, ICT? Delegates must demonstrate that the following has been completed within 30 calendar days of receiving the trigger report through documentation in the patient’s record:

Retrieval and review of the trigger report

Clinical review (HRA, assessment, utilization data, other relevant clinical data – see definition attached)

Outreach to the patient (minimum of 3 attempts within 2 weeks)

Outcome of patient conversation and identification of plan of care

Activities taken when patient unable to be contacted/declined care management

Development or update of the Care Plan (ICP) based on all identified triggers

Interdisciplinary care team (ICT) activities

Plan of care communicated to the patient and PCP

2. Some of the RN NFLOC reports are 10-12 plus pages. What are the expectations to capture all of this data? Some have 39 parts to the care plan.

The nursing facility level of care (NFLOC) is a state mandated assessment to identify those members that are at a higher need level of care that meet nursing facility level of care. These members receive additional benefits.

The care plan is provided to delegates to support their care management process in the identification of triggers, patient concerns, and interventions.

Delegates must demonstrate review and consideration of each care plan element and integration into their care management review.

3. Are members on the Trigger Report the same ones that we get from the HRA? Would there ever be a

member on the Trigger report that there is no HRA? How come for some members, we only received ICP but no HRA?

Yes, members on the trigger report are the same as the HRA report.

All members on the trigger report should have a corresponding HRA, however there are a couple of instances when you will not receive an associated HRA:

When a member is unable to be reached to complete the HRA, SCAN creates a generic care plan to support the member and delegate’s care management process.

If SCAN has pended the HRA, the HRA will be delivered at a later date

4. If the NFLOC is an HRA, why do we sometimes get both a few weeks to months apart? After we receive the HP HRA, we reach out to the member, then we receive the RN NFLOC, do we reach out to the member once again?

Generally, HRAs are completed prior to the NFLOC assessment. If the member was identified as needing Long-Term Services and Supports, they are referred for a NFLOC assessment. Hence there may be multiple HRAs.

Delegates must demonstrate that the following has been completed within 30 calendar days of receiving the trigger report, through documentation in the patient’s record:

Retrieval and review of the trigger report Clinical review (HRA, assessment, utilization data, etc.) Outreach to the patient (minimum of 3 attempts within 2 weeks) Outcome of patient interview and identification of plan of care Activities taken when patient unable to be contacted/declined CM Development or update the Care Plan (ICP) Interdisciplinary care team (ICT) activities Plan of care communicated to the patient and PCP

Health Risk Assessment (HRA)

2

SNP MOC Training 2019 – FAQ Sheet (cont...)

5. Please clarify for unable to reach members, we need to "share the care plan"?

It is a SNP requirement that all members are assessed and have a care plan

For members that you are unable to reach, a care plan must be developed based on available member data including, but not limited to:

Clinical documents, trigger reports, medication lists, utilization data (authorizations, claims), diagnoses, social information, or SDOH challenges.

The care plan is then sent to the member and PCP.

6. Do care plans need to be diagnosis based?

No. Care plans are a documented process to identify the member’s medical and non-medical issues and concerns (problems) to ensure that everyone on the care team is supporting the interventions and member outcomes.

Care plans address all triggers and member concerns identified during the HRA process and lists interventions and actions to be addressed in the future.

Individualized Care Plan (ICP)

7. Is a Social Worker required for the ICT?

The interdisciplinary care team (ICT) should include those care team members to support the members identified issues and needs.

These team members can change over time based on changes in member’s condition and identified needs.

8. What is the definition of "Medical Expert" to participate in the ICT? Do they have to be physically present at the formal ICT or can the CM discuss case over the phone with the "medical expert".

A “Medical Expert” can be a PCP, Specialist, Geriatrician or other physician provider.

ICT can be done through collaboration with the appropriate “Medical Experts” on the phone, in a formal meeting, via email, etc.

Delegates must demonstrate collaboration in their documentation.

Care Transitions (CT)

Interdisciplinary Care Team (ICT)

9. What if there is no care plan for a member undergoing a transition?

If there has been no care plan developed and the member is in transition, the delegate must demonstrate that the following has been completed through documentation:

Clinical review (HRA, assessment, utilization data, etc.) Outreach to the patient (minimum of 3 attempts within 2 weeks) Outcome of patient interview and identification of plan of care Activities taken when patient unable to be contacted/declined CM Development or update the Care Plan (ICP) Interdisciplinary care team (ICT) activities Plan of care communicated to the patient and PCP

10. Do you need to call a member on transition between settings (ex: hospital to SNF) or only once discharged

home? Presenter stated once home.

Best practice is to initiate care transitions prior to discharge (from any facility) to ensure that the patient’s needs will be met upon discharge.

Delegates must demonstrate patient outreach and care transition activities within 5 business days of discharge.

3

11. What if member discharge to hospice. Do we still do Care transition, create care plan, call member, and log

to Care transition log?

For members transitioning to hospice, it is important to remember that coordination of standard (non-hospice) care remains the responsibility of the medical group.

Delegates must demonstrate that the care plan has been updated based on the identified needs of the member and collaboration with the hospice provider to ensure the member’s needs are being met.

12. Some of hospital follow up appointments take more than 2 weeks due to volume. How do we address?

The expectation is that the groups follow the “Access and Availability standards” to coordinate with their Medical Directors to provide member care.

13. For the 5 days member outreach and PCP notification, what regulatory body requires it: NCQA? CMS?

We adopted the ICE template recommendations and changed from 3 days to 5 days for discharge notification for both member and PCP outreach. We want to align our expectations with other health plans. The industry collaborative (ICE) worked with area health plans to identify timelines for the CT intervention.

14. What are the parameters for home visits?

All D-SNP members identified as being eligible for LTSS benefits require a NFLOC assessment performed by a SCAN Field Care Manager.

15. What is the SCAN requirements for member outreach? We reach out to the member with two phone calls

and the third is a letter will this be okay?

Documentation must demonstrate 3 telephonic patient outreach attempts. (Minimum of 3 separate attempts, daily, within a 1 - 2 week timeframe).

16. I always understood a SNP case could not be closed. However, presenter stated that they will close after

30, 60, 90 days. So, a case can be closed if patient meets goals or no longer wants to participate?

Please follow your organizational care management protocol.

SNP cases may be closed after meeting organizational criteria

17. With all these audits and requirements from CMS and DHS, who and what IT or some kind of AI assistance entity has SCAN consulted or looking into consulting to assist w/ making all these care planning and audits sustainable, consistent and replicable so nurses can focus on empowering wellness w/our members than paperwork focused so much?

SCAN acknowledges the challenges you experience in applying these requirements and agree that the focus must be on empowering wellness. Please work with your assigned HCS contact and auditor to collaborate on quality improvement opportunities. We look forward to working with you.

18. Will you please provide us with the most recent information about the pals program and how to contact

them?

Enclosed is a fact sheet on the PAL team, including a contact email for Lisa Desai at SCAN for more information or to connect directly with a member's PAL.

19. Are the PALs available to talk with the Medical Group case managers? Or are they only for the members.

The Personal Assistance Line (PAL) Program is a dedicated, non-clinical care coordination unit with specialized SCAN employees trained to respond to questions about Medicare and Medicaid benefits and to assist with care coordination, identification and access to needed care and services.

Yes, you can call our PALS.


Other

4

11.


20. Is there a way that social workers can identify those members who are Medi-Medi (Connections or Connections at Home)? Many times, we cannot determine what plan they are on to assist with social work outreach, especially with HRA's we receive for follow up? Is there a plan code that we can utilize?

Refer to the SNP Monthly Membership Report that is posted on the SNP sftp site on the 2nd day of each month.

This report identifies all SNP members that are active with your medical group and their current plan type description.

Initial Health Assessment (IHA)

21. Slide 22 referenced IHA due at 120 days and 90 days. Confused as to time frame IHA needs to be done by. Is a medicare IHA due by 90 of enrollment and Medical 120? Or are you changing the requirement to be for both medi-CAL and Medicare to be within 90 days?

The Special Need Plan (SNP) members are members with Medicare and Med-Cal benefits. Based on the dual eligibility, the Medi-Cal guidelines apply for these members.

The Medi-Cal requirement for IHA/SHA is 120 days and Medicare is 90 days. To make it consistent, SCAN require 90 days for all.

22. When will these days of IHA requirement be enforced? For future audit timeline.

These guidelines are currently in effect.

Care Transition

Clinical Review Components: Patient/Member demographics

a. Age

b. Language

c. Availability of transportation

d. Social support and living situation

Benefits

HRA Responses

NFLOC

Trigger Report

Presence of Advance Directive or End of Life Plan (AHCD, POLST, DPOA) a. Goals of care

Care Level / Acuity based on criteria (identification of acuity and existing acuity)

Problem List (Concerns and Management)

a. Observed and reported

Current medical records

a. CM Notes/Assessments

i. 6 months of notes

b. Office visits (PCP and Specialists)

i. 12 months of care visits including Urgent Care

c. Medication list

i. Pharmacy claims data, refill gaps, High risk meds, are members on 8+ meds

d. Lab reports (especially related to chronic conditions)

e. Facility admits/discharges within past 12 months

i. Care Transitions

f. Patient/Member education

g. Current care plan (PGIs)

i. Care plan updates within past 6 months

h. Behavioral Health needs / Substance Use

Interdisciplinary Care Conferences

Change in Health Status: 1. Access to care challenges

2. Admission/Discharge from a facility (e.g., acute, rehab, SNF, LTC)

3. Additional chronic diagnosis since last review

4. New medications, high risk medications, or changes in medications (Why, Education, Understanding)

5. New Patient/Member concern(s)

6. Changes in lab data related to chronic condition (e.g., HbA1c, Cholesterol)

7. Changes in functional status (e.g., falls, cognition, ADLs, IADLs)

8. Adherence challenges (appointments, medications, plan of care)

9. Other pertinent conditions

Clinical Review & Change in Health Status Guidelines

Fact Sheet

March 2019

Personal Assistance Line (PAL) SCAN offers a dedicated customer service unit with specialized SCAN employees trained to respond to questions from Dual Eligible Members about their Medicare and Medi-Cal benefits and to assist with care coordination and identification and access to needed care and services. The SCAN Personal Assistance Line (PAL) conducts outbound calls to welcome dual eligible members to SCAN and receives inbound calls on a dedicated toll-free number.

Criteria:

Dually enrolled members - members with Medicare and Medicaid

Interventions:

Welcome Call conducted within the first 90 days of enrollment o Reviews SCAN Medicare and Medicaid benefits o Reviews how the managed care system works: the primary care physician’s role,

how to get referrals to specialists, medications, etc. o Facilitates an Initial Health Assessment (IHA) and Staying Healthy Assessment

(SHA) appointment with the primary care physician o Identifies continuity of care issues, such as getting authorization with the new

medical group for oxygen, hospital beds, and specialist services o Completes initial and annual Special Needs Plan Health Risk Assessments (HRA) o Screens the member for case management needs based on pre-established

criteria, as well as long-term services and support needs

Follows up with medical groups and providers to ensure that members receive their referrals, acts as a liaison between the member, medical groups, and SCAN case management programs

Assists members with their transportation benefit to medical appointments

Identifies and assists with Medi-Cal eligibility issues

Educates the member on Grievance and Appeals process/State Fair Hearings

Goals:

Improve customer service and experience

Provide culturally and linguistically appropriate services

Increase member satisfaction and retention

Reduce barriers and access to care issues

For more information, contact Lisa Amin Desai, Manager, Care Coordination, at 562-637-1228 or [email protected]