Training for CarePoint Health Plans Staff


Published on

  • Be the first to comment

  • Be the first to like this

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

Training for CarePoint Health Plans Staff

  1. 1. A CarePoint Medicare Advantage and I-SNP training presentation
  2. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 20. Priorities  Member centered  Provider driven  Focused on Best Practices, both clinical and managerial
  21. 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. 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. 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. 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. 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. 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. 27. Member Physician Preventive Health Acute & Chronic Care Rehab LTC End of Life Care
  28. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 39. Member Member Member Nursing Facility Community Acute Care Facility Mid-Level Provider Mid-Level Provider Mid-Level Provider Plan of Care
  40. 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. 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. 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. 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. 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: