SNP Training – Topic 3: Structure & Process Measures 1 through 3 March 12, 19, 25 and April 23,...
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Transcript of SNP Training – Topic 3: Structure & Process Measures 1 through 3 March 12, 19, 25 and April 23,...
SNP Training – Topic 3: Structure & Process Measures 1
through 3
March 12, 19, 25 and April 23, 2009
2SNP Training #3: SNP Structure & Process Measures 1 thru 3
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.
3SNP Training #3: SNP Structure & Process Measures 1 thru 3
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
4SNP Training #3: SNP Structure & Process Measures 1 thru 3
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
5SNP Training #3: SNP Structure & Process Measures 1 thru 3
Three-Year StrategyPhase 1 - FY
2008 Phase 2 - FY 2009 Phase 3 - FY 2010
SNPs Effective as of January 2007
SNPs Effective as of January 2008
SNPs Effective as of January 2008
HEDIS 2008(13 measures)
HEDIS 2009(15 measures)•Addition of two new 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
Structure & Process Measures
• SNP1 – 3• SNP 4: Care Transitions• SNP 5: Institutional SNP
Relationship with Facility• SNP6: Coordination of
Medicare & Medicaid
Structure & Process Measures
•Refinement of existing S&P measures, includes the potential development of new elements
•Potential development of new measures
6SNP Training #3: SNP Structure & Process Measures 1 thru 3
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
7SNP Training #3: SNP Structure & Process Measures 1 thru 3
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)
8SNP Training #3: SNP Structure & Process Measures 1 thru 3
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 Assessment
10SNP Training #3: SNP Structure & Process Measures 1 thru 3
SNP Assessment Process
• Phased Approach– Defining and assessing desirable
structural characteristics– Assessing processes– Assessing outcomes
• Two main components – HEDIS Measures-focus on clinical
performance– Structure & Process measures-focus on
structural characteristics and systems
11SNP Training #3: SNP Structure & Process Measures 1 thru 3
S&P 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
12SNP Training #3: SNP Structure & Process Measures 1 thru 3
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.
13SNP Training #3: SNP Structure & Process Measures 1 thru 3
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:
14SNP Training #3: SNP Structure & Process Measures 1 thru 3
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.
15SNP Training #3: SNP Structure & Process Measures 1 thru 3
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 1: Complex Case Management
17SNP Training #3: SNP Structure & Process Measures 1 thru 3
SNP 1: Complex Case SNP 1: Complex Case ManagementManagement
• The organization helps members with multiple or complex conditions to obtain access to care and services and coordinates their care
NCQA Definition: Complex Case ManagementThe 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
18SNP Training #3: SNP Structure & Process Measures 1 thru 3
SNP 1: Element ASNP 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.
19SNP Training #3: SNP Structure & Process Measures 1 thru 3
SNP 1: Element A FAQs
• What type of information is NCQA looking for?– Documented processes or reports that
demonstrate the SNP is using various data sources to identify eligible members for CM
• What if a plan automatically enrolls all members in CM?– Plans that auto-enroll and maintain all members
in CM can provide evidence of this and receive 100% for this element
• What if CCM is part of larger DM program?– SNPs must have a CCM program. This program
may be part of a broader DM program, but the SNP must demonstrate that it meets the requirements for CCM.
20SNP Training #3: SNP Structure & Process Measures 1 thru 3
SNP 1: Element A ExamplesDocumentation 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 member’s prognosis; cost and utilization data; catastrophic pharmacy claims; disability claims; and aggregate claims exceeding certain thresholds.
21SNP Training #3: SNP Structure & Process Measures 1 thru 3
SNP 1: Element BSNP 1: Element B
• Access to Case Management: Plan is open to referrals from other sources to consider members for CM
– Health information line referral – DM program referral – Discharge planner referral – UM referral, if applicable – Member self-referral – Practitioner referral – Other referrals (must specify what these are)
22SNP Training #3: SNP Structure & Process Measures 1 thru 3
SNP 1: Element B FAQs
• What type of information is NCQA looking for?– Documented processes, reports or materials
that demonstrate the SNP allows referrals from multiple sources
• Does a SNP have to enroll every member referred for CM?– No. Plans do not have to enroll every member
referral, but must consider them
• Health information line referral is not required for Medicare, do the SNPs have to have this?– This factor may be scored “NA,” but if a SNP
has an HIL, it must accept referrals
23SNP Training #3: SNP Structure & Process Measures 1 thru 3
SNP 1: Element B Examples
Documentation may include:• A policy for the case management referral
process that identifies which persons or entities refer members for services
• A description which indicates how the organization uses the data sources to confirm case management referrals are appropriate for: members need for long-term monitoring, interventions and support
• A flowchart detailing the steps of the case management process and persons used as referral resources within it
24SNP Training #3: SNP Structure & Process Measures 1 thru 3
SNP 1: Element CSNP 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
25SNP Training #3: SNP Structure & Process Measures 1 thru 3
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
26SNP Training #3: SNP Structure & Process Measures 1 thru 3
SNP 1: Element C
• Documentation for Factor 1 may include:
– Online scripts and checklists that allow case managers to obtain information on interventions in evidence-based care plan by physician, any care gaps or mitigating circumstances and assess the member’s compliance with the care plan
– Screen shots supplemented with policies or descriptions that specify how the case manager performs the assessment activities
– Flow charts that include descriptions of assessment process activities and the clinical evidence used in the process
• Documentation for Factors 2 and 3 must include:– Screen shots from electronic case management systems
that capture the date, time, user ID, action by the case manager along with reminders and follow-up due dates; policies or usage instructions accompany these screen shots
27SNP Training #3: SNP Structure & Process Measures 1 thru 3
SNP 1: Element DSNP 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
28SNP Training #3: SNP Structure & Process Measures 1 thru 3
SNP 1: Element D FAQs
• What if a plan automatically enrolls all members in CM?– Plans that auto-enroll and maintain all members
in CM can receive 100% for this element(if they provide appropriate documentation)--also applies to SNP 1A, 1B and 1E Factor 2
• What type of information is NCQA looking for?– Documented processes or reports that
demonstrate the frequency with which SNPs systematically identify eligible members for CM
29SNP Training #3: SNP Structure & Process Measures 1 thru 3
SNP 1: Element ESNP 1: Element E
• Providing Members With InformationDoes the SNP give members written and verbal information on:
– How to use the services – How members become eligible to participate
– How to opt in or opt out
30SNP Training #3: SNP Structure & Process Measures 1 thru 3
SNP 1: Element E
• What type of data sources is NCQA looking for?– To demonstrate performance on this element, the
SNP must provide:• Documented processes that describe the process for
notifying members; and• Materials provided to members
• In some states, SNPs are required to provide CM to all members, so “opt out” should not apply– Factor 3 is “NA” if the organization is required by
states or others to provide case management to all members
31SNP Training #3: SNP Structure & Process Measures 1 thru 3
SNP 1: Element FSNP 1: Element F
• Case Management Process
– Member’s 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
32SNP Training #3: SNP Structure & Process Measures 1 thru 3
SNP 1: Element F SNP 1: Element F (cont. …)(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
33SNP Training #3: SNP Structure & Process Measures 1 thru 3
SNP 1: Element F FAQs
• Can Plans use screen shots from a computerized questionnaire or case management system to show compliance with this element?– Yes, provided the screen shots display the
fields with the relevant questions related to the factors
34SNP Training #3: SNP Structure & Process Measures 1 thru 3
SNP 1: Element F ExamplesEvidence that addresses requirements in each of the fourteen factors may consist of:
• Policies and procedures which delineate the case manager’s 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.
35SNP Training #3: SNP Structure & Process Measures 1 thru 3
SNP 1: Element GSNP 1: Element G
• Informing and Educating Practitioners
– Instructions on how to use CM services – How the organization works with a
practitioner’s patients in the program
36SNP Training #3: SNP Structure & Process Measures 1 thru 3
SNP 1: Element G FAQs
• What type of information is NCQA looking for?– To demonstrate performance on this
element, the organization must provide:•Documented processes that describe its
process for notifying practitioners; and •Materials provided to practitioners
• Examples of materials include:– Provider manuals– Training brochures – information on Organization’s Website
SNP 2: Improving Member Satisfaction
38SNP Training #3: SNP Structure & Process Measures 1 thru 3
SNP 2: Element ASNP 2: Element A
• Assessment of Member Satisfaction
– Identify the appropriate population – Draw appropriate samples from the affected
population, if a sample is used– Collect valid data
*Plans with no enrollment as of the start of the look-back period are exempt from this element
39SNP Training #3: SNP Structure & Process Measures 1 thru 3
SNP 2: Element A FAQs
• Does the member satisfaction apply only to the SNP’s 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. – SNPs can use CAHPS data they have analyzed
to satisfy this element in place of analyzing complaints and appeals
40SNP Training #3: SNP Structure & Process Measures 1 thru 3
SNP 2: Element A FAQs
• If we do not pull a sample and analyze member satisfaction data for our entire SNP population will NCQA score Factor 2 NA?– NCQA scores Factor 2 “Yes” when an
organization analyzes member satisfaction data for its entire SNP population
• How recent must the data be for this element?– Data must be collected no more than 12
months prior to the look back period
41SNP Training #3: SNP Structure & Process Measures 1 thru 3
SNP 2: Element BSNP 2: Element B
• Opportunities for Improvement
– Plans must review their data and determine how best to improve
– Identify opportunities
* Plans with no enrollment as of the start of the look-back period are exempt from this element
42SNP Training #3: SNP Structure & Process Measures 1 thru 3
SNP 2: Element B FAQs
• What if no opportunities for improvement are identified?– If no opportunities are identified in the SNP’s
analysis, and NCQA surveyors agree with this conclusion, the element is scored “NA.”
• Do SNPs have to show improvement based on the opportunities identified? – Plans undergoing the SNP Evaluation for the
first time in 2009 are not required to demonstrate they have taken action on the identified opportunities
– Plans that completed the SNP Evaluation in 2008 must provide evidence of actions taken and a plan to evaluate its actions
SNP 3: Clinical Quality Improvements
44SNP Training #3: SNP Structure & Process Measures 1 thru 3
SNP 3: Element ASNP 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• Plans must demonstrate that each of the 3 clinical issues
is relevant to its membership.
*Plans with no enrollment as of the start of the look-back period are exempt from this element
45SNP Training #3: SNP Structure & Process Measures 1 thru 3
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 undergoing the SNP Evaluation for the first
time in 2009 are not required to identify opportunities or demonstrate they have taken action to show improvement
– Plans that completed the SNP Evaluation in 2008 must demonstrate they identified opportunities and decided which ones to pursue.
46SNP Training #3: SNP Structure & Process Measures 1 thru 3
SNP 3: Element A FAQs
• Can a SNP submit service-oriented performance measures and meet SNP 3A?– No, measures for this element must
involve improvements in the quality of clinical care
• Should a SNP use a particular format for its documentation?– The ISS Survey tool contains a
supplemental worksheet plans can use to demonstrate performance
47SNP Training #3: SNP Structure & Process Measures 1 thru 3
General FAQs
• Could you clarify the look-back period and whether a SNP must develop or review all of its documentation within that this timeframe?– The look-back period is the three-month period
prior to survey submission—March 31, 2009 to June 30, 2009. All documentation must be current as of the look-back period but it could have been developed before that time.
– For evidence consisting of a policy, an organization that did not have one in place can develop and incorporate it into its operations during the look-back period.
48SNP Training #3: SNP Structure & Process Measures 1 thru 3
General FAQs
• We contract with other entities (medical groups) to perform a number of the functions assessed by the Structure and Process measures. How should we demonstrate performance with these requirements?– Your organization needs to provide the
appropriate evidence from these contracted entities to documenting their performance. In addition you should discuss the details of this documentation with a member of the SNP Team.
Additional Resources
50SNP Training #3: SNP Structure & Process Measures 1 thru 3
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
51SNP Training #3: SNP Structure & Process Measures 1 thru 3
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
52SNP Training #3: SNP Structure & Process Measures 1 thru 3
Policy Clarification Support (PCS)
• 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
53SNP Training #3: SNP Structure & Process Measures 1 thru 3
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
54SNP Training #3: SNP Structure & Process Measures 1 thru 3
Policy Clarification Support (PCS)
Menu options under “Standard/Measures”• If “SNP – Structure & Process” was
selected: – SNP 1: Complex Case Management – SNP 2: Improving Member Satisfaction – SNP 3: Clinical Quality Improvements – SNP 4: Care Transitions– SNP 5: Institutional Relationship with Facilities– SNP 6: Coordination of Medicare and Medicaid
Services– Other
55SNP Training #3: SNP Structure & Process Measures 1 thru 3
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
56SNP Training #3: SNP Structure & Process Measures 1 thru 3
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
57SNP Training #3 – SNP Structure & Process Measures 1 thru 3
Contacts
Brett KayDirector, SNP [email protected]
Casandra MonroeAssistant Director, SNP [email protected]
58SNP Training #3: SNP Structure & Process Measures 1 thru 3
Questions?