Training for CarePoint Health Plans Staff
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  • 1. A CarePoint Medicare Advantage and I-SNP training presentation
  • 2.  CarePoint Health Plans is an insurance company that shares ownership with Bayonne Medical Center, Christ Hospital and Hoboken University Medical Center  CarePoint is currently licensed in Hudson County  CarePoint Health Plans has a contract with the Centers for Medicare and Medicaid Services (CMS) to offer an MAPD plan and an I-SNP plan
  • 3.  A Medicare Advantage plan combines traditional Medicare A & B  Medicare Advantage (or Part C) is managed care Medicare  The coverage is provided by a private (non- governmental) insurance company  Anyone who has Medicare A & B, lives in the coverage area, and does NOT have End-Stage Renal Disease is also eligible for a Medicare Advantage plan  Medicare Advantage plans are usually offered with Part D (prescription drug) coverage as well and are known as MAPD plans.
  • 4.  Prescription drugs are covered under Medicare Part D  Most Medicare Advantage plans include prescription drug coverage under Part D – if the plan offers Part D, a member must get their coverage under it  A Medicare Advantage plan that offers Part D is called an MAPD plan
  • 5.  A Special Needs Plan is a Medicare plan that limits enrollment to members with specific diseases or characteristics and tailors benefits to best meet their needs  An I-SNP is an Institutional Special Needs Plan  This is a Medicare managed care plan for individuals who, for 90 days or longer, have had or are expected to need LTC SNF, LTC NF, SNF/NF, ICF/MR or inpatient psychiatric level of care. Individuals in the community may be enrolled if they also require the institutional level of care.  I-SNP eligibility must be verified independently, using the State-approved assessment tool, such as the PASRR, OASIS, MDS, and documentation from the individual’s physician.
  • 6.  Premiums and benefits differ between CarePoint’s MAPD and I-SNP. ◦ CarePoint Advantage (MAPD PPO) $0 additional premium (still pay Part B premium) ◦ CarePoint Guardian (I-SNP PPO) $37 monthly premium  Refer to the Summary of Benefits and Evidence of Coverage for differences between traditional Medicare, CarePoint Advantage and CarePoint Guardian
  • 7.  Imperative to adhere to all CMS Marketing Guidelines  Potential members MUST request an appointment – NO REFERRALS and NO SOLICITATION  Potential members may be identified: ◦ At Sales & Marketing and Educational events ◦ By approaching a clearly-identified Sales & Marketing representative ◦ By contacting a Sales & Marketing representative as a result of seeing approved marketing material or at the suggestion of another individual ◦ I-SNP eligibility MUST be verified BEFORE a Sales & Marketing meeting can be scheduled with the individual
  • 8.  A Medicare Advantage plan can be either an HMO or a PPO – currently, CarePoint’s plans are PPOs  The Primary Care Physician must be in-network in both types of plans  Both HMO and PPO must have appropriate access to primary care and specialists in-network  “Network Adequacy” includes: number and specialty of providers, distance and travel time to providers within the community the Plan serves
  • 9.  Provider network includes primary care and specialist physicians, mid-level providers, allied health practitioners, tertiary care facilities, lab, x-ray, home health, transportation and others  Often, additional providers are contracted for services not available within the network (example: transplant surgery, cardiac surgery)  Occasionally an out-of-network provider may be contracted for a single patient and/or a single case  All network providers are subject to the Plan’s Credentialing process and Quality measures and,  All staff and providers will participate in orientation to this model of care on a yearly basis
  • 10.  In an HMO the member receives all care in- network, and referrals are usually required  In a PPO the member may go out-of-network for care – the cost-sharing is usually higher. For CarePoint Advantage the member has a 30% cost-share for most out-of-network services  PPOs do not require referrals  In both types of plans approval, also known as Prior Authorization, for certain types of tests is often required (example: CT scans, MRI, endoscopy)
  • 11.  Improve care through: ◦ Improving access to care  Network primary care and specialty physicians including Behavioral Health  Assess health care needs and respond  Access to additional resources  Maintenance of health care coverage ◦ Improving coordination of care  Utilize care managers, nurse practitioners  Provide clear explanation of available benefits and how to access
  • 12.  Provide care that is coordinated across settings  Improve member health with best practice preventive health services  Make certain members receive: ◦ The right care ◦ In the right setting ◦ In the right amount ◦ At the right time ◦ For the right member  Monitor member health and provider practices to assure improvement in positive health outcomes
  • 13.  Owned by the same owners as the hospitals  Administrative staff roles and responsibilities ◦ Executive management ◦ Provider network and relations ◦ Compliance ◦ Finance ◦ Sales & Marketing ◦ Customer service ◦ Claims payment ◦ Information technology ◦ Human resources
  • 14.  Clinical staff roles and responsibilities ◦ Chief medical officer ◦ Director of Quality ◦ Director of Care Management  Case & Disease Management  Utilization review ◦ Appeals and Grievances ◦ Pharmacy management
  • 15.  Patient care is provided primarily by CarePoint’s network of providers  Members receive care across the entire spectrum of settings, from outpatient to observation, inpatient, rehabilitation and skilled nursing facility.  Because a Medicare Advantage plan is offered by a managed care organization, care is coordinated for the member in all settings.
  • 16.  Care coordination is accomplished using a variety of resources: ◦ Physicians and other providers ◦ Care and Case Managers ◦ Mid-level providers (e.g. nurse practitioners) ◦ Nurses ◦ Discharge planners ◦ Home health care agencies ◦ Social workers ◦ Area Agencies on Aging ◦ Community- and faith-based organizations ◦ Others
  • 17.  Communication ◦ A critical component of the coordination of care ◦ Include all stakeholders ◦ Coordinate care between member, family, members of care team ◦ Provide information using multiple forms of media including mail, e-mail, Web, member and provider portals, phone, fax, face to face meetings, video conferencing, member handbook, member newsletter, provider manual, information packages, provider profiles, policies & procedures, inter- disciplinary care team meetings
  • 18.  CarePoint provides a robust IT care management system to track: ◦ Member health ◦ Quality of care ◦ Member plans of care ◦ Medical/surgical, behavioral, radiology, laboratory and pharmacy encounter and claims information ◦ Metrics to support the above measures plus HEDIS and others  Information is shared with members of the integrated health care system to improve: ◦ Quality of care ◦ Access to care ◦ Overall health outcomes ◦ Efficiency ◦ Productivity
  • 19.  Guided by the members’ health status, CarePoint may provide management in the form of: ◦ Automated information provided by mail, e-mail or phone ◦ Individualized information provided by phone by a care manager ◦ Personalized visits by a mid-level provider  This information may relate to a member’s: ◦ Medications ◦ Upcoming appointments for provider visits, testing or procedures ◦ Prescription order updates ◦ Recommendations for health care management.
  • 20. Priorities  Member centered  Provider driven  Focused on Best Practices, both clinical and managerial
  • 21. Patient Centered Care  Manage care across the continuum using ◦ Primary Care Physicians ◦ Mid-level providers ◦ Coordinate community-based/faith-based services ◦ Leverage additional resources  Pro-actively manage population and individual care ◦ Identify care needs and gaps in care early and intervene before the member’s condition worsens  Focus on the member/family experience
  • 22.  All members (MAPD & I-SNP) will complete a Health Risk Assessment (HRA) upon enrollment; assistance will be provided to those who are unable to do this on their own  The HRA will be incorporated in the Plan’s medical management system to generate a Clinical Risk Assessment  This Clinical Risk Assessment will be used by the Plan to provide the most appropriate care management resources for the member  As additional diagnostic and pharmacy data is obtained about the member, this clinical risk assessment will be refined using the Johns Hopkins ACG System
  • 23.  The Health Risk Assessment contains questions regarding ◦ Family history ◦ Personal health status ◦ Activities of daily living (ADLs) ◦ Medications ◦ Use of/Need for special services ◦ Use of preventive services ◦ Pain ◦ Fear of falling ◦ Mental health and cognitive function ◦ Nutrition/Exercise/Health habits ◦ Tobacco/Substance use and abuse ◦ Social supports ◦ Quality of life
  • 24.  Clinical Risk Assessment ◦ Medical Care Management staff at CarePoint will use the information to:  Create a Plan of Care based on nationally-accepted Clinical Practice Guidelines and coordinate this Plan of Care with the member’s primary care physicians  Analyze the member’s care history to identify gaps in care and upcoming needs (barriers to care and interventions)  Determine appropriate care management tools for member – phone calls, written material by mail, e-mail reminders, assignment of mid-level provider for members at higher risk  Members must be given the option to not participate in care management – the Plan will continue to monitor their health status and they may opt-in at any time
  • 25.  Member engagement will be promoted with a variety of methods including:  Motivational interviewing (“What’s important to you? What would it mean to you to get it? What would it mean if you didn’t?”)  Direct contact from Care Management staff  Culturally appropriate health information available in a variety of media  Incentives when legally permissible and appropriate
  • 26.  Empower practitioners ◦ Information on best practices ◦ Identification of gaps in care ◦ Objective data on individual practice versus peers ◦ Provide clinical management tools ◦ Emphasis on preventive care
  • 27. Member Physician Preventive Health Acute & Chronic Care Rehab LTC End of Life Care
  • 28. Mid-Level Providers (NP)  Deploy across continuum of care  Improve access to care  Refer members to Primary Care Physician office  Provide efficient, evidence-based care  Enhance provider-member engagement, communication and productivity  Coordinate resources
  • 29. Member Physician Mid-Level Provider (NP) Timely Access to Care Care Coordination Early Warning Clinical Risk Management Agency on Aging Social Services CBO/FBO
  • 30.  The I-SNP Model of Care introduces additional resources to care for institutionalized and institutional-equivalent members, and most importantly, those most vulnerable (multiple chronic conditions and/or medications, dual diagnosis, end of life) identified by Care Management and the team of practitioners ◦ Inter-Disciplinary Care Team ◦ INTERACT II care management method and tools ◦ Enhanced care coordination
  • 31.  Inter-Disciplinary Care Team (IDCT) ◦ All I-SNP members will have an IDCT comprising representatives of the coordinated care team ◦ New members of the IDCT will be included to address developments in the member’s care needs ◦ Member and family participation is actively encouraged. Invitations and meeting summary letters are sent ◦ The IDCT meets regularly, updates the Plan of Care as necessary, and may additionally meet should there be a change in condition of the member ◦ Best-Practice care will be coordinated, and will include the use of IT infrastructure and prior-authorization
  • 32.  Additional components of model of care ◦ Care providers use INTERACT II  Empowers everyone in the institution to improve the quality of care  Clinical and educational tools and strategies to manage changes in resident condition  Improve quality with early identification, assessment, documentation and communication  Resources to manage end of life care as well  Examples of INTERACT II clinical tools follow:  STOP AND WATCH and the SBAR documentation tool
  • 33. INTERACT Early Warning Tool – STOP AND WATCH  Seems different than usual  Talks or communicates less than usual  Overall needs more help than usual  Participated in activities less than usual  Ate less than usual (Not because of dislike of food)  N  Drank less than usual  Weight change  Agitated or nervous more than usual  Tired, weak, confused, or drowsy  Change in skin color or condition  Help with walking, transferring, toileting more than usual
  • 34. INTERACT II “PROGRESS NOTE” - SBAR  Physician/NP/PA Communication and Progress Note  For New Symptoms, Signs and Other Changes in Condition  Before Calling MD/NP/PA:  Evaluate the resident and complete the SBAR form (use “N/A” for not applicable)  Check VS: BP, pulse, respiratory rate, temperature, pulse ox, and/or finger stick glucose if indicated  Review chart: recent progress notes, labs, orders  Review relevant INTERACT II Care Path or Acute Change in Status File Card  Have relevant information available when reporting (i.e. resident chart, vital signs, advanced directives such as DNR and other care limiting orders, allergies, medication list)
  • 35. SBAR DETAILS  S SITUATION  The symptom/sign/change I’m calling about is _______________________________________________________  ____________________________________________________________________________________________  This started___________________________________________________________________________________  This has gotten (circle one) worse/better/stayed the same since it started  Things that make the condition worse are ___________________________________________________________  Things that make the condition better are ___________________________________________________________  Other things that have occurred with this change are __________________________________________________  B BACKGROUND  Primary diagnosis and/or reason resident is at the nursing home _________________________________________  Pertinent history (e.g. recent falls,fever, decreased intake, pain, SOB, other) ________________________________  _____________________________________________________________________________________________  Vital signs BP_________/__________ HR ________________ RR ________________ Temp ________________  Pulse Oximetry ____________% On RA___________on O2 at ______________L/min via___________ (NC, mask)  Change in function or mobility ____________________________________________________________________  Medication changes or new orders in the last two weeks _______________________________________________  Mental status changes (e.g. confusion/agitation/lethargy) ______________________________________________  GI/GU changes (circle) (e.g. nausea/vomiting/diarrhea/impaction/distension/decreased urinary output/other)  Pain level/location ______________________________________________________________________________  Change in intake/hydration _______________________________________________________________________  Change in skin or wound status ___________________________________________________________________  Labs ________________________________________________________________________________________  Advance directives (circle) (Full code, DNR, DNI, DNH, other, not documented)  Allergies __________________________________ Any other data ______________________________________  A ASSESSMENT (RN) OR APPEARANCE (LPN)  (For RNs): What do you think is going on with the resident? (e.g. cardiac, infection, respiratory, urinary, dehydration,  mental status change?) I think that the problem may be ____________________________________________-OR  I am not sure of what the problem is, but there had been an acute change in condition.  (For LPNs): The resident appears (e.g. SOB, in pain, more confused) _____________________________________  R REQUEST  I suggest or request (check all that apply):  Provider visit (MD/NP/PA) Monitor vital signs and observe  Lab work, x-rays, EKG, other tests Change in current orders _______________________  IV or SC fluids New orders __________________________________  Other (specify) ________________________ Transfer to the hospital  Staff name ____________________________________________________________________________RN/LPN  Reported to: Name ____________________________(MD/NP/PA) Date____/____/____ Time________a.m./p.m.  If to MD/NP/PA, communicated by: Phone In person  Resident name _______________________________________________________________________________
  • 36. INTERACT II tools at the bedside for early identification & assessment  Care Paths ◦ Dehydration ◦ Fever ◦ Mental status change ◦ Symptoms of CHF ◦ Symptoms of lower respiratory tract infection ◦ Symptoms of UTI
  • 37.  Value-added benefits ◦ Nursing facilities will have free WiFi, resident e- mail, Internet café ◦ Wanderguard ® - to identify individuals who have wandered from allowed areas ◦ Delayed egress magnetic locking doors – to prevent elopement ◦ Pet therapy ◦ Video-conferencing for members and their families
  • 38.  Care Transitions ◦ Members in MAPD & I-SNP will be managed across the continuum of care ◦ Mid-level providers will manage transitions with the members’ physicians to assure continuity of care, medication reconciliation, and adherence to the Plan of Care
  • 39. Member Member Member Nursing Facility Community Acute Care Facility Mid-Level Provider Mid-Level Provider Mid-Level Provider Plan of Care
  • 40.  Bi-directional exchange of information  Expanded population stratification  Pro-active care management and gap analysis  Analytics  Robust clinical metrics ◦ Based on HEDIS/NCQA -> 5-Star ◦ Provider profiling and appropriate corrective action
  • 41. Member Physician Mid-Level Provider (NP) CarePoint Health Plans Education Best Practices Metrics Predictive Modeling Risk Stratification Care Management Empowerment Education Healthier Members Healthier Population Improved Care Experience Efficient, High- Quality, Cost- Effective Care
  • 42. Quality – Making sure we’re doing it right!  MAPD & I-SNP Quality Management Steering Committee ◦ Supported by:  Medical Care Management Committee  Medical Standards Committee  Grievance & Appeal Committee  Credentialing Committee  Pharmacy & Therapeutics Committee ◦ Coordinated with Compliance Committee  Quality indicators measure process and outcomes of care.  Quality indicators, overall and by provider, will be monitored, tracked and trended and compared to benchmarks and goals.
  • 43.  Indicators and Goals: ◦ Provider Access Standards – 90% for all providers ◦ Appointment Availability Standards – 90% for all providers ◦ % of members who selected a PCP ◦ % of MDS completed in 30 days – 100% ◦ % of Plans of care completed within 5 days of transition – 100% ◦ % of members who received flu and pneumovax vaccine – increase by 5-10% ◦ HEDIS® Effectiveness of Care measures – meet 50th percentile of NCQA ◦ % of avoidable re-admissions – reduce by 3-5% ◦ % of inappropriate ER utilization – reduce by 3-5% ◦ Rate of falls – reduce rate of falls with injuries 1-2% ◦ Rate of decubitus ulcers – reduce by 2% ◦ Rate of quality of care complaints – reduce by 2%
  • 44. Please download and print the following statement, sign and date, and return it to CarePoint. Thank you. CarePoint MOC attestation  Questions?  David J. Sand, MD, MBA, FACS ◦ Chief Medical Officer, CarePoint Health Plans ◦ Phone: 201-432-2133 ext. 106 ◦ E-mail: dsand@carepoint.org