snp training – topic 4: structure & process measures 4 through 7 march 17, 24, 31 and april 2,...

SNP Training – Topic 4: Structure & Process Measures 4

through 7

March 17, 24, 31 and April 2, 7,15, 2009

2SNP Training #4: SNP Structure & Process Measures 4 thru 7

Objective of S&P Measures Training

• Describe the SNP assessment project NCQA is executing on behalf of CMS

• Explain the intent of the S&P 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 strategy

• 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 year—rapid turnaround, adapted

existing NCQA measures and processes from voluntary Accreditation programs

– 2nd year—focus on SNP-specific measures– 3rd year—Refine measures; identify new

SNP-specific measures, where appropriate


Three-Year StrategyPhase 1 - FY

2008 Phase 2 - FY 2009 Phase 3 - FY 2010

SNPs Effective as of January 2007



HEDIS 2008(13 measures)

HEDIS 2009(15 measures)•Addition of two measures: Care for Older Adults; Medication Reconciliation Post-Discharge

HEDIS 2010 • Measure development:

–Potentially Avoidable Hospitalizations–Inpatient Readmissions–MDS measures (I-SNPs)–Disease-specific measures (C-SNPs)

Structure & Process Measures

• SNP 1: Complex Case Management

• SNP 2: Improving Member Satisfaction

• SNP 3: Clinical Quality Improvements


• SNP1 – 3• SNP 4: Care Transitions• SNP 5: Institutional SNP

Relationship with Facility• SNP6: Coordination of

Medicare & Medicaid


•Refinement of existing S&P measures, includes the potential development of new elements

•Potential development of new measures


Who Reports

• HEDIS measures– All SNP plan benefit packages with 30+

members as of February 2008 Comprehensive Report (CMS website)

• S&P measures– All SNP plan benefit packages– Plans with no enrollment exempt from

certain elements


What to Report

• S&P measures• Cohort I—All SNPs operational as of

January 1, 2007 and renewed in 2009.– S&P measures 4-7 (SNP 2:C & 3:B)

• Cohort II—All SNPs operational as of January 1, 2008 and renewed in 2009– All S&P measures (SNP 1-6)

•Do not report SNP 7 (SNP 2:C & 3:B)


Project Time Line – Phase II

• March 4- Release final S&P measures• March 30 - Release ISS Data

Collection Tool– S & P Measures

• April - Release IDSS Data Collection Tool– HEDIS Measures

• June 30 - HEDIS submissions and S&P 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 AssessmentAisha Pittman, Senior Health Care Analyst, Performance

Measurement


S&P measures: What’s New for 2009

• SNP 1-3: Added 2 new elements (SNP 7 in ISS)– SNP 2C (SNP 7A): Improving member

satisfaction• Focus on implementing interventions to address

member satisfaction issues

– SNP 3B (SNP 7B): Clinical measurement activities

• Focus on collecting, analyzing relevant clinical data• Identifying opportunities for improvement based on

data analysis

– Existing elements: added more examples and clarified explanations


S&P Measure Development Process

• Identify highest ranking priorities in coordination with GMAP (2/08)

• Conduct plan interviews (5/08)• Draft measures with assistance

from SNP TEP (6/08)• Conduct Pilot Test with plans (7/08)• Release measures for public

comment (10/08)• Finalize (1/09)


Objectives of New S&P Measures: SNP 4 Care Transitions

• Overall focus on SNP-specific functions• All members: Monitoring members’

movement between care settings– Ensuring transfer of information such as

medication and care plans– Initially more emphasis on monitoring

transitions to and from acute care settings– In subsequent years, measures will assess

monitoring all aspects of all care transitions


Objectives of New S&P Measures: SNP 5 Institutional SNP Relationship with

Facility• Institutionalized members:

Monitoring members care– Plans should monitor members health

status quarterly– Plans should ensure that changes in

members health status are responded to quickly

– In subsequent years, measures will assess quality of health status information collected


Objectives of New S&P Measures: SNP 6 Coordination of Medicare &Medicaid• Dual-eligible members: Members should

feel as if they are seamlessly enrolled in one plan– Plans should identify members’ eligible Medicaid

and Medicare benefits and services and assist them in obtaining them

– Plans should work with state Medicaid agencies to contract to provide Medicaid benefits

– This element assesses plans progression towards meeting MIPPA requirements

– In subsequent years, the measure will assess plans ability to integrate Medicare and Medicaid


Components of the S&P Measures

• Standard statement: a statement about acceptable performance or results

• Intent statement: A sentence that describes the importance of the S&P 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 S&P measure.


Components of an S&P 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 S&P Measure

• Scope of Review: The extent of the organization’s services evaluated during an NCQA survey.

• Look-back period: The period of time for which NCQA evaluates an organization’s documentation to assess performance against an element

• Explanation: Guidance for demonstrating performance against the element

• Example: Descriptive information illustrating performance against an element’s requirements. Examples are for guidance and are not intended to be all-inclusive

SNP 4: Care Transitions


SNP 4: Element ASNP 4: Element AManaging TransitionsManaging Transitions

• Managing & coordinating planned/unplanned transitions from one care setting to another

– Factors 1& 2 focus on transitions to and from a hospital

– Factors 3-6 focus on transitions to and from other care settings

– Factor 7 requires an analysis of plans’ management of transitions

• Focus is providing information and communication from one setting to another:

– Providers/practitioners– Caregivers– patients


SNP 4: Element ASNP 4: Element AManaging TransitionsManaging Transitions

• Documentation– Documented processes AND Reports or

materials– Must specify a timeframe for completion of

required transition activities in factors 3-6 – Transitions to/from hospital must address

activities in factors 1-6– Transitions to/from other care settings must

address activities in factors 3-6, at a minimum


SNP 4: Element A FAQs

• Does NCQA want to see an analysis for Factor 7, or just a plan to conduct the analysis?– SNPs may present a plan or process that

details how it will conduct an analysis. The actual analysis is not required this year.

• Can SNPs provide job descriptions of staff responsible for managing transitions?– Yes. SNPs may provide job descriptions

as an example of materials detailing transition coordination activities.


SNP 4: Element A Examples• Policies & procedures for supporting

members’ moves b/w care settings, including items to be completed by each setting

• Policies & procedures for communicating with members or responsible parties

• Formats for reports used to identify planned transitions, changes in member health status and hospitalizations ordered by providers

• Information prepared for members experiencing transitions.


SNP 4: Element BSNP 4: Element B

Identifying Unplanned Transitions

• Review the following information for network facilities:

– hospital admissions w/in one business day of admission

– LTC facility admissions w/in one business day of admission

• Organization or member’s usual practitioner must manage the transition


SNP 4: Element B

• Documentation: organization must provide both:

– Documented processes, AND

– Reports•Examples to show plan implements its

policies


SNP 4: Element B FAQs

• Can the organization use reports from its staff who regularly see members in hospitals and LTC facilities?– Yes. The reports may come from organization staff

or from the facilities directly. They may also come from UM or other standard reporting processes.

• Should a SNP provide actual patient data in the admissions reports?– No. Plans should NOT send any personal health

information (PHI). All patient identifiable data should be removed.

– Report formats or shells of daily admissions reports are sufficient for this element.


SNP 4: Element B Examples

Documentation may include:•Procedures for reporting by contracted

facilities– Must include the organization’s time frame for

receiving reports

•Procedures for organization staff to report on members’ transitions

•Format or shell of daily admissions reports from hospitals

•Format or shell of organization staff notification of member transitions, based on organization staff visits to facilities or contact with facility staff


SNP 4: Element CSNP 4: Element CReducing TransitionsReducing Transitions

Focus is on minimizing unplanned transitions and keeping patients in least restrictive setting

• Analyze individual member data to identify those at risk

• Patient-specific data

• Coordinate services for at-risk members • High-risk members

• Educate members/caregivers-prevent unplanned transitions

• Analyze member admissions—hospitals and ED visits• Annual analysis to identify areas for improvement• Population focus (aggregate data)


SNP 4: Element CSNP 4: Element CReducing TransitionsReducing Transitions

Documentation: SNPs must provide:

• Documented processes AND

• Reports– Formats or shells for factor 1– Actual analysis for factor 4


SNP 4: Element C FAQs

• Can an organization use the data it collects from its case management program (SNP 1: Complex Case management, Elements A, B, & D) to meet the requirements of factor 1?– Yes, provided the organization analyzes

information on all members with the same frequency as it does for case management, to predict possible transitions for individual members

• Can an organization assign responsibility for factors 1, 2, 3 to other providers?– Yes. However, the organization is ultimately

responsible for meeting the requirements.


SNP 4: Element CExamples

• Documented Processes– Procedures for case managers to contact at-risk

members to assess needs and arrange services– Procedures for ordering needed services or working

with providers to order them

• Reports– Format or shell of reports identifying high-risk

patients using claims or other data– Format or shell showing predictive modeling to

assign members a risk score– Reports on overall rates of admissions and ED

visits, analysis of root causes and opportunities for improvement

SNP 5: Institutional SNP Relationship with Facility


SNP 5: Institutional SNP Relationship with Facility

• Institutional SNPs only– Focus is on communications with

facilities to monitor member needs and services provided

• Dual Eligible and Chronic Care SNPs are exempt– Score all elements in this measure

“NA”


SNP 5: Element A

• Organization monitors information on member health status at least quarterly– Scoring is 100% or 0% (all or nothing

element)– Communication should include information

that may indicate a change in health status or no change

• Status reports may include:– Functional status assessments– Medication regimen– Self-reported health status– Reports on falls, socialization and depression


SNP 5: Element A

• Documentation: SNPs must provide:

• Documented processes AND

• Reports or materials



• If an organization collects the required data as part of its case management functions, will that meet the requirements for this element?– Yes, provided the data is collected at least

quarterly• Can SNPs use data derived from MDS

or other systematic data collection?– Yes. MDS or other reports specified by the

SNP from the institutional facility that report on member health status are acceptable


SNP 5: Element A Examples

• Documented Processes– Procedures for network facilities to provide

ongoing updates on member health– Contracts or agreements with facilities

covering their monitoring and reporting responsibilities

• Reports?– Format or shells of reports of staff visits to

facilities to collect member health status info• Materials

– Facility briefing materials


SNP 5: Element B SNP 5: Element B Monitoring Changes in Members’ Monitoring Changes in Members’

Health StatusHealth Status

• Requires network institutions to notify SNP or treating practitioner with 24-48 hours of change in members’ health status

• Organization sets parameters for:

– Triggering events/changes to report

– Who should be contacted (plan or practitioner)

– Timeframe for reporting


SNP 5: Element B SNP 5: Element B Monitoring Changes in Members’ Monitoring Changes in Members’

Health StatusHealth Status

Documentation Requires • Documented processes; AND

– Procedures for network facility to provide notification

– Contracts or agreements with facilities covering their reporting responsibilities

• Reports or materials– Format or shell of reports of member health change

reports from staff visits

– Format or shell of member health change reports from facilities



• Can a SNP require different timeframes for notification for different issues such as falls, weight loss, etc?– Yes. The SNP may set its own notification parameters,

however, they cannot exceed 48 hours to receive full credit for this element

• When does the timeframe for notification start, at the time of the health status change or the identification of that change?– The timeframe begins once someone (facility or SNP

staff) identifies that an eligible health status change or triggering event has occurred. For example, a member gets a fever at 3:00am, but it is not observed or recorded until 6:00am. The timeframe for notification to the SNP/practitioner starts at 6:00am.


SNP 5: Element C Maintaining Members’ Health Status

• Organizations use the information from SNP 5: Elements A&B to identify at-risk members and work with facilities/practitioners to arrange for necessary care and adjust care plans as needed to prevent declines in member health status


SNP 5: Element C

Documentation must include: • Documented Processes; AND

– Policies and procedures for how the organization and facilities respond to triggering events and changes in health status

– Contracts or agreements with facilities covering their reporting responsibilities

• Materials– Job descriptions of staff who visit members in

facilities– Facility briefing materials


SNP 5 Element C Examples

Methods of providing care: • Organizations may have differing models

of relationships with facilities to address these monitoring functions– Facility oversight: relies on facilities to

modify/carry out care plans– Staff practitioners: SNP staff practitioners

visit facilities and order care plan modifications

– Other models of care: SNPs may use a combination of above models or different one

SNP 6: Coordination of Medicare and Medicaid Coverage


SNP 6: Element A Administrative SNP 6: Element A Administrative Coordination for Dual-Eligible Coordination for Dual-Eligible

BenefitBenefit The organization coordinates Medicare &

Medicaid benefits/services by:• Providing members (current & prospective) with

information on both programs• Providing information about maintaining Medicaid

eligibility• Identifying changes in member Medicaid eligibility• Giving members access to staff knowledgeable about

both programs• Coordinating adjudication of Medicare/Medicaid

claims • Providing clear explanations of rights to pursue

grievances/appeals under both programs• Providing clear explanations of benefits and any

communications they receive re: claims, cost sharing



• If we are an Institutional SNP, do we have to complete this element?– No. SNP 6: Element A is applicable only to Dual-eligible SNPs.

Institutional and Chronic care SNPs should select “NA” in the survey tool for this element and document that they are either an I-SNP or C-SNP

• We operate in a state that does not allow us to integrate our marketing materials for Medicare & Medicaid. How can we demonstrate compliance with this element?– Plans that operate in states where integrated marketing or

other member information is not permitted may provide separate benefit materials to members/prospective members, e.g., one brochure on the Medicare benefits and one for the Medicaid benefits.


SNP 6: Element A Examples

• SNPs must provide documented processes and may provide any one of the other two data sources to meet element requirements:– Documented processes:

• Job descriptions for staff who help members with coordination of both sets of benefits

• Procedures used to determine changes in Medicaid eligibility

– Materials:• Sample marketing materials; brochures, benefit summaries• Instructions on where to reapply for Medicaid

– Reports:• Format or shell of reports on Medicaid eligibility used by

organization


SNP 6: Element BRelationship with State Medicaid

Agency

The organization has a documented relationship with the state Medicaid agency to promote coordinated care

• For Dual-eligible SNPs only that:– Have a contract/agreement with state

agency– Are working toward a contract/ agreement


SNP 6: Element B Documentation

• SNPs may provide documentation from any one of the data sources– Documented Processes:

• Contracts or agreements with the state Medicaid agency covering administration or benefits

• Procedures for administering Medicaid benefits, where the procedures reflect an ongoing process

– Reports: • Written notification of a scheduled meeting with state to

discuss contracting w/in past 12 months or notification acknowledging receipt of, or action on, organization’s proposal for contracting to administer Medicaid benefits w/in past 12 months

– Materials:• Instructional materials from state agency on how to

administer Medicaid benefits



• Our SNP operates in a state that refuses to contract with Medicare health plans to coordinate or administer Medicaid benefits. How can we comply?– In situations where the state cannot or will

not enter into an agreement with the SNP, the SNP may take an “NA” for this element. SNPs must document this with a letter or legislation/regulations from the state that indicate such refusal/inability to act



• Our SNP is in the process of developing a relationship with the state agency, but it is not finalized. How can we meet the requirements?– SNPs may provide a letter or proposal that

documents an ongoing effort to establish a relationship with the state

• What are the valid types of agreements SNPs can enter into with states?– SNPs may have a contract, an MOU, or MOA


SNP 6: Element C Administrative Coordination for

Chronic and Institutional SNPs

• Organization coordinates Medicare/Medicaid benefits for C-SNP& I-SNP members by:– Using a process to identify changes in member

Medicaid eligibility– Informing members about maintaining Medicaid

eligibility– Giving eligible members information about

Medicare/Medicaid benefits– Giving members access to staff knowledgeable

about both programs


SNP 6: Element C

• Similar to SNP 6: Element A• Applies only to C-SNPs and I-SNPs

with more than 5% of dual-eligible members– Dual-eligible SNPs are exempt from this

element

• For overlapping factors (with SNP 6:A), same requirements for documentation and expectations


SNP 6: Element DService Coordination

• Organization coordinates delivery of services covered by Medicare/Medicaid through the following:– Helping members access network providers that

participate in both programs or accept Medicaid patients

– Educating providers about coordinating benefits for which members are eligible and about members’ special needs

– Educating members about both benefits– Helping members obtain services funded by either

program when needed– Assessing adequacy of provider network semi-

annually to ensure access to care *Element is NA for C-SNPs & I-SNPs w/less than 5%

dual eligible members


SNP 6: Element D

• SNPs must provide the following documentation:– Documented processes; AND

• P&Ps for arranging services for members

– Reports or Materials• Reports on access indicators such as percentage

of in-network and out-of-network use; rate of ED use compared to norms in area; or member surveys of satisfaction with access

• Materials such as the provider directory; provider manuals; sample benefit summaries


SNP 6: Element D FAQs

• Can a SNP assign responsibility for arranging services (Medicare/Medicaid) to its network practitioners and other affiliated providers (nursing facilities)?– Yes. SNPs may assign the services required

in factors 3 & 4. SNPs are responsible for maintaining an adequate network and for educating network practitioners and providers about their role in coordinating services, but can coordinate the other functions in different ways.


SNP 6: Element D FAQs

• What are the physician requirements for services that are reimbursed by Medicare & Medicaid for dual-eligible members?– The organization must require it’s network

physicians to do one of the following:• Accept both Medicare & Medicaid payment and

cannot bill patients more than allowable state co-pays, or

• Do not balance-bill dual-eligible members for the Medicaid co-pays (if only accepting Medicare)


SNP 7: Element A (SNP 2:C)

• Member Satisfaction: Improving Satisfaction—Builds on elements from Phase I requirements (SNP 2:A & SNP 2:B)– The organization works to improve member

satisfaction by:• Implementing interventions• Developing a plan for evaluation of the

intervention


SNP 7: Element A

• SNPs must provide the following documentation:– Documented processes demonstrating the

evaluation plans; AND– Reports demonstrating the implementation

of the intervention.



• Can a SNP identify and implement opportunities other than the ones it originally identified in SNP 2: Element B?– Yes. A SNP may identify and implement other

opportunities but it must provide documentation demonstrating that the opportunity resulted from the analysis in accordance with SNP 2: Element A.

• What if a SNP received an NA last year for SNP 2:B because it didn’t have adequate member satisfaction data to identify opportunities?– A SNP must do a new analysis using its current data,

identify opportunities AND implement interventions and a plan for evaluation of the interventions.



• What if a SNP did not identify any opportunities in SNP 2:B last year based on its data analysis because it didn’t have any members?– SNPs must provide new analysis this year if they have

more members and are able to identify opportunities based on the new analysis. For SNPs with no members as of the start of the look-back period, they are exempt from completing this element.

• Can a SNP incorporate its intervention evaluation plan as part of an annual assessment of member satisfaction?– Yes, but the organization may not use data generated

before the intervention was implemented.


SNP 7:B Clinical Measurement Activities (SNP 3:B)

• The organization works to improve clinical issues by:– Collecting data appropriate for the

clinical issues– Analyzing the collected data– Identifying opportunities for

improvement and deciding which ones to pursue

• Builds on clinical measures identification from SNP 3: Element A


SNP 7: Element B

• Data Analysis– Quantitative analysis--must include a first-

level, quantitative analysis of data, including comparison of results with a goal or benchmark and past performance (if previous measure performed)

– Qualitative analysis—identify reasons for results and potential barriers to improvement.

• Data collected must be no older than 12 months prior to the start of the look-back period


Questions?

Additional Resources


Additional Resources

• NCQA SNP Web page www.ncqa.org/snp.aspx

– FAQs (HEDIS)– Training descriptions & schedule– S&P measures

• NCQA Policy Clarification Support (PCS)http://app04.ncqa.org/pcs/web/asp/TIL_ClientLogin.asp

• HEDIS Audit informationhttp://www.ncqa.org/tabid/204/Default.aspx


Policy Clarification Support (PCS)

• PCS Web address

http://app04.ncqa.org/pcs/web/asp/TIL_ClientLogin.asp

• Link for SNP Web pagewww.ncqa.org/snp.aspx



• 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


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 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– (MRP) Medication Reconciliation Post-Discharge– (BCR) Board Certification– (HOS) Medicare Health Outcomes Survey– Other



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

Services– Other


Additional SNP Trainings

• SNP Subset of HEDIS Measures– March 3rd 11:30 – 1:00– March 11th 11:30 – 1:00 – March 16th 1:00 - 2:30 – March 26th 1:00 - 2:30– April 1st 12:30 - 2:00

• Structure and Process Measures (S&P 1-3)– March 12th 1:00 – 2:30– March 19th 1:00 - 2:30, – March 25th 12:30 - 2:00– April 23rd 2:00 – 3:30


Additional SNP Seminars

• Structure and Process Measures (S&P 4-6)– March 17th 2:00 - 3:30– March 24th 2:00 - 3:30 – March 31st 2:00 - 3:30– April 2nd 12:30 – 2:00– April 7th 2:00 - 3:30– April 15th 1:00 – 2:30

• Interactive Survey System (ISS)– April 8th 1:00 – 2:30– April 14th 1:00 - 2:30, – April 17th 1:00 – 2:30 – April 21st 1:00 - 2:30– April 28th 1:00 – 2:30– May 7th 1:00 – 2:30

74SNP Training #3 – SNP Structure & Process Measures 1 thru 3

Contacts

Brett KayDirector, SNP [email protected]

Casandra MonroeAssistant Director, SNP [email protected]

snp training – topic 4: structure & process measures 4 through 7 march 17, 24, 31 and april 2,...

Documents

sp measures snp

snpspecific measures

snp structure process

measures hedis

new snp specific measures

measures addition

sp measures submissions

snp assessment report