Please complete and upload this document into HPMS.
|
SNP Contract Name (as provided in HPMS)
|
Enter contract name here.
|
SNP CMS Contract Number
|
Enter contract number here.
(Also list other contracts where this MOC is
applicable.)
|
Care Management Plan Outlining the Model of Care
|
In the following table, list the document, page number, and
section of the corresponding description in your care management
plan for each model of care element.
|
Model of Care Elements
|
Corresponding Document
Page Number/Section
|
Description
of the SNP Population:
Element
A: Description of the Overall SNP Population: The
identification and comprehensive description of the SNP-specific
population is an integral component of the MOC because all of the
other elements depend on the firm foundation of a comprehensive
population description. The organization must provide information
about its local target population in the service areas covered
under the contract. Information about national population
statistics is insufficient. It must provide an overview that fully
addresses the full continuum of care of current and potential SNP
beneficiaries, including end-of-life needs and considerations, if
relevant to the target population served by the SNP. The
description of the SNP population must include, but not be limited
to, the following:
Clear documentation of how
the health plan staff determines or will determine, verify,
and track eligibility of SNP beneficiaries.
A detailed profile of the
medical, social, cognitive, environmental, living conditions,
and co-morbidities associated with the SNP population in the
plan’s geographic service area.
Identification and
description of the health conditions impacting SNP
beneficiaries, including specific information about other
characteristics that affect health such as, population
demographics (e.g. average age, gender, ethnicity, and
potential health disparities associated with specific groups
such as: language barriers, deficits in health literacy, poor
socioeconomic status, cultural beliefs/barriers, caregiver
considerations, other).
Define unique characteristics
for the SNP population served:
Element
B: Sub-Population: Most Vulnerable Beneficiaries
As
a SNP, you must include a complete description of the
specially-tailored services for beneficiaries considered
especially vulnerable using specific terms and details (e.g.,
members with multiple hospital admissions within three months,
“medication spending above $4,000”). The description
must differentiate between the general SNP population and that of
the most vulnerable members, as well as detail additional benefits
above and beyond those available to general SNP members. Other
information specific to the description of the most vulnerable
beneficiaries must include, but not be limited to, the following:
A description of the
relationship between the demographic characteristics of the most
vulnerable beneficiaries with their unique clinical requirements.
Explain in detail how the average age, gender, ethnicity,
language barriers, deficits in health literacy, poor
socioeconomic status and other factor(s) affect the health
outcomes of the most vulnerable beneficiaries.
The identification and
description of the established partnerships with community
organizations that assist in identifying resources for the most
vulnerable beneficiaries, including the process that is used to
support continuity of community partnerships and facilitate
access to community services by the most vulnerable beneficiaries
and/or their caregiver(s).
|
|
2. Care
Coordination:
Care coordination helps ensure
that SNP beneficiaries’ healthcare needs, preferences for
health services and information sharing across healthcare staff
and facilities are met over time. Care coordination maximizes the
use of effective, efficient, safe, and high-quality patient
services that ultimately lead to improved healthcare outcomes,
including services furnished outside the SNP’s provider
network as well as the care coordination roles and
responsibilities overseen by the beneficiaries’
caregiver(s). The following MOC sub-elements are essential
components to consider in the development of a comprehensive care
coordination program; no sub-element must be interpreted as being
of greater importance than any other. All five sub-elements
below, taken together, must comprehensively address the SNPs’
care coordination activities.
SNP Staff Structure
Fully define the SNP staff roles
and responsibilities across all health plan functions that
directly or indirectly affect the care coordination of
beneficiaries enrolled in the SNP. This includes, but is not
limited to, identification and detailed explanation of:
Specific employed and/or
contracted staff responsible for performing administrative
functions, such as: enrollment and eligibility verification,
claims verification and processing, other.
Employed and/or contracted
staff that perform clinical functions, such as: direct
beneficiary care and education on self-management techniques,
care coordination, pharmacy consultation, behavioral health
counseling, other.
Employed and/or contracted
staff that performs administrative and clinical oversight
functions, such as: license and competency verification, data
analyses to ensure appropriate and timely healthcare services,
utilization review, ensuring that providers use appropriate
clinical practice guidelines and integrate care transitions
protocols.
Provide a copy of the SNP’s
organizational chart that shows how staff responsibilities
identified in the MOC are coordinated with job titles. If
applicable, include a description of any instances when a change
to staff title/position or level of accountability was required
to accommodate operational changes in the SNP.
Identify the SNP contingency
plan(s) used to ensure ongoing continuity of critical staff
functions.
Describe how the SNP conducts
initial and annual MOC training for its employed and contracted
staff, which may include, but not be limited to, printed
instructional materials, face-to-face training, web-based
instruction, and audio/video-conferencing.
Describe how the SNP documents
and maintains training records as evidence to ensure MOC training
provided to its employed and contracted staff was completed. For
example, documentation may include, but is not limited to: copies
of dated attendee lists, results of MOC competency testing,
web-based attendance confirmation, and electronic training
records.
Explain any challenges
associated with the completion of MOC training for SNP employed
and contracted staff and describe what specific actions the SNP
will take when the required MOC training has not been completed
or has been found to be deficient in some way.
Health Risk Assessment Tool
(HRAT)
The quality and content of the
HRAT should identify the medical, functional, cognitive,
psychosocial and mental health needs of each SNP beneficiary. The
content of, and methods used to conduct the HRAT have a direct
effect on the development of the Individualized Care Plan and
ongoing coordination of Interdisciplinary Care Team activities;
therefore, it is imperative that the MOC include the following:
Description of how the HRAT is
used to develop and update, in a timely manner, the
Individualized Care Plan (MOC Element 2C) for each beneficiary
and how the HRAT information is disseminated to and used by the
Interdisciplinary Care Team (MOC Element 2D).
Detailed explanation for how the
initial HRAT and annual reassessment are conducted for each
beneficiary.
Detailed plan and rationale for
reviewing, analyzing, and stratifying (if applicable) the results
of the HRAT, including the mechanisms to ensure communication of
that information to the Interdisciplinary Care Team, provider
network, beneficiaries and/or their caregiver(s), as well as
other SNP personnel that may be involved with overseeing the SNP
beneficiary’s plan of care. If stratified results are
used, include a detailed description of how the SNP uses the
stratified results to improve the care coordination process.
Individualized Care Plan
(ICP)
The ICP components must include,
but are not limited to: beneficiary self-management goals and
objectives; the beneficiary’s personal healthcare
preferences; description of services specifically tailored to the
beneficiary’s needs; roles of the beneficiaries’
caregiver(s); and identification of goals met or not met.
Explain the process and which
SNP personnel are responsible for the development of the ICP, how
the beneficiary and/or his/her caregiver(s) or representative(s)
is involved in its development and how often the ICP is reviewed
and modified as the beneficiary’s healthcare needs change.
If a stratification model is used for determining SNP
beneficiaries’ health care needs, then each SNP must
provide a detailed explanation of how the stratification results
are incorporated into each beneficiary’s ICP.
Describe how the ICP is
documented and updated as well as, where the documentation is
maintained to ensure accessibility to the ICT, provider network,
beneficiary and/or caregiver(s).
Explain how updates and/or
modifications to the ICP are communicated to the beneficiary
and/or their caregiver(s), the ICT, applicable network providers,
other SNP personnel and other stakeholders as necessary.
Interdisciplinary Care Team
(ICT)
Provide a detailed and
comprehensive description of the composition of the ICT; include
how the SNP determines ICT membership and a description of the
roles and responsibilities of each member. Specify how the
expertise and capabilities of the ICT members align with the
identified clinical and social needs of the SNP beneficiaries,
and how the ICT members contribute to improving the health status
of SNP beneficiaries. If a stratification model is used for
determining SNP beneficiaries’ health care needs, then each
SNP must provide a detailed explanation of how the stratification
results are used to determine the composition of the ICT.
Explain how the SNP
facilitates the participation of beneficiaries and their
caregivers as members of the ICT.
Describe how the beneficiary’s
HRAT (MOC Element 2B) and ICP (MOC Element 2C) are used to
determine the composition of the ICT; including those cases
where additional team members are needed to meet the unique
needs of the individual beneficiary.
Explain how the ICT uses
healthcare outcomes to evaluate established processes to manage
changes and/or adjustments to the beneficiary’s health
care needs on a continuous basis.
Identify and explain the use of
clinical managers, case managers or others who play critical
roles in ensuring an effective interdisciplinary care process is
being conducted.
Provide a clear and
comprehensive description of the SNP’s communication plan
that ensures exchanges of beneficiary information is occurring
regularly within the ICT, including not be limited to, the
following:
Clear evidence of an
established communication plan that is overseen by SNP
personnel who are knowledgeable and connected to multiple
facets of the SNP MOC. Explain how the SNP maintains effective
and ongoing communication between SNP personnel, the ICT,
beneficiaries, caregiver(s), community organizations and other
stakeholders.
The types of evidence used to
verify that communications have taken place, e.g., written ICT
meeting minutes, documentation in the ICP, other.
How communication is conducted
with beneficiaries who have hearing impairments, language
barriers and/or cognitive deficiencies.
Care Transitions Protocols
Explain how care transitions
protocols are used to maintain continuity of care for SNP
beneficiaries. Provide details and specify the process and
rationale for connecting the beneficiary to the appropriate
provider(s).
Describe which personnel (e.g.,
case manager) are responsible for coordinating the care
transition process and ensuring that follow-up services and
appointments are scheduled and performed as defined in MOC
Element 2A.
Explain how the SNP ensures
elements of the beneficiary’s ICP are transferred between
healthcare settings when the beneficiary experiences an
applicable transition in care. This must include the steps that
need to take place before, during and after a transition in care
has occurred.
Describe, in detail, the process
for ensuring the SNP beneficiary and/or caregiver(s) have access
to and can adequately utilize the beneficiaries’ personal
health information to facilitate communication between the SNP
beneficiary and/or their caregiver(s) with healthcare providers
in other healthcare settings and/or health specialists outside
their primary care network.
Describe how the beneficiary
and/or caregiver(s) will be educated about indicators that
his/her condition has improved or worsened and how they will
demonstrate their understanding of those indicators and
appropriate self-management activities.
Describe how the beneficiary
and/or caregiver(s) are informed about who their point of contact
is throughout the transition process.
|
|
SNP
Provider Network:
The SNP Provider Network is a
network of healthcare providers who are contracted to provide
health care services to SNP beneficiaries. The SNP is responsible
for a network description that must include relevant facilities
and practitioners necessary to address the unique or specialized
health care needs of the target population as identified in MOC 1,
and provide oversight information for all of its network types.
Each SNP is responsible for ensuring their MOC identifies, fully
describes, and implements the following for its SNP Provider
Network:
Specialized Expertise
Provide a complete and detailed
description of the specialized expertise available to SNP
beneficiaries in the SNP provider network that corresponds to the
SNP population identified in MOC Element 1.
Explain how the SNP oversees its
provider network facilities and ensures its providers are
actively licensed and competent (e.g., confirmation of applicable
board certification) to provide specialized healthcare services
to SNP beneficiaries. Specialized expertise may include, but is
not limited to: internal medicine, endocrinologists,
cardiologists, oncologists,, mental health specialists, other.
Describe how providers
collaborate with the ICT (MOC Element 2D) and the beneficiary,
contribute to the ICP (MOC Element 2C) and ensure the delivery of
necessary specialized services. For example, describe: how
providers communicate SNP beneficiaries’ care needs to the
ICT and other stakeholders; how specialized services are
delivered to the SNP beneficiary in a timely and effective way;
and how reports regarding services rendered are shared with the
ICT and how relevant information is incorporated into the ICP.
Use of Clinical Practice
Guidelines & Care Transitions Protocols
Explain the processes for
ensuring that network providers utilize appropriate clinical
practice guidelines and nationally-recognized protocols. This
may include, but is not limited to: use of electronic databases,
web technology, and manual medical record review to ensure
appropriate documentation.
Define any challenges
encountered with overseeing patients with complex healthcare
needs where clinical practice guidelines and
nationally-recognized protocols may need to be modified to fit
the unique needs of vulnerable SNP beneficiaries. Provide
details regarding how these decisions are made, incorporated into
the ICP (MOC Element 2C), communicated with the ICT (MOC Element
2D) and acted upon.
Explain how SNP providers
ensure care transitions protocols are being used to maintain
continuity of care for the SNP beneficiary as outlined in MOC
Element 2E.
MOC Training for the Provider
Network
Explain, in detail, how the SNP
conducts initial and annual MOC training for network providers
and out-of-network providers seen by beneficiaries on a routine
basis. This could include, but not be limited to: printed
instructional materials, face-to-face training, web-based
instruction, audio/video-conferencing, and availability of
instructional materials via the SNP plans’ website.
Describe how the SNP documents
and maintains training records as evidence of MOC training for
their network providers. Documentation may include, but is not
limited to: copies of dated attendee lists, results of MOC
competency testing, web-based attendance confirmation, electronic
training records, and physician attestation of MOC training.
Explain any challenges
associated with the completion of MOC training for network
providers and describe what specific actions the SNP Plan will
take when the required MOC training has not been completed or is
found to be deficient in some way.
|
|
4. MOC
Quality Measurement & Performance Improvement:
The goals of performance
improvement and quality measurement are to improve the SNP’s
ability to deliver healthcare services and benefits to its SNP
beneficiaries in a high-quality manner. Achievement of those goals
may result from increased organizational effectiveness and
efficiency by incorporating quality measurement and performance
improvement concepts used to drive organizational change. The
leadership, managers and governing body of a SNP organization must
have a comprehensive quality improvement program in place to
measure its current level of performance and determine if
organizational systems and processes must be modified based on
performance results.
MOC Quality Performance
Improvement Plan
Explain, in detail, the quality
performance improvement plan and how it ensures that appropriate
services are being delivered to SNP beneficiaries. The quality
performance improvement plan must be designed to detect whether
the overall MOC structure effectively accommodates beneficiaries’
unique healthcare needs. The description must include, but is not
limited to, the following:
The complete process, by which
the SNP continuously collects, analyzes, evaluates and reports
on quality performance based on the MOC by using specified data
sources, performance and outcome measures. The MOC must also
describe the frequency of these activities.
Details regarding how the SNP
leadership, management groups and other SNP personnel and
stakeholders are involved with the internal quality performance
process.
Details regarding how the
SNP-specific measurable goals and health outcomes objectives
are integrated in the overall performance improvement plan (MOC
Element 4B).
Process it uses or intends to
use to determine if goals/outcomes are met, there must be
specific benchmarks and timeframes, and must specify the
re-measurement plan for goals not achieved.
Measureable Goals &
Health Outcomes for the MOC
Identify and clearly define the
SNP’s measureable goals and health outcomes and describe
how identified measureable goals and health outcomes are
communicated throughout the SNP organization. Responses must
include but not be limited to, the following:
Specific goals for improving
access and affordability of the healthcare needs outlined for
the SNP population described in MOC Element 1.
Improvements made in
coordination of care and appropriate delivery of services
through the direct alignment of the HRAT, ICP, and ICT.
Enhancing care transitions
across all healthcare settings and providers for SNP
beneficiaries.
Ensuring appropriate
utilization of services for preventive health and chronic
conditions.
Identify the specific
beneficiary health outcomes measures that will be used to measure
overall SNP population health outcomes, including the specific
data source(s) that will be used.
Describe, in detail, how the SNP
establishes methods to assess and track the MOC’s impact on
the SNP beneficiaries’ health outcomes.
Describe, in detail, the
processes and procedures the SNP will use to determine if the
health outcomes goals are met or not met.
Explain the specific steps the
SNP will take if goals are not met in the expected time frame.
C. Measuring Patient
Experience of Care (SNP Member Satisfaction)
Describe the specific SNP
survey(s) used and the rationale for selection of that particular
tool(s) to measure SNP beneficiary satisfaction.
Explain how the results of SNP
member satisfaction surveys are integrated into the overall MOC
performance improvement plan, including specific steps to be
taken by the SNP to address issues identified in response to
survey results.
D. Ongoing Performance
Improvement Evaluation of the MOC
Explain, in detail, how the SNP
will use the results of the quality performance indicators and
measures to support ongoing improvement of the MOC, including how
quality will be continuously assessed and evaluated.
Describe the SNP’s ability
to improve, on a timely basis, mechanisms for interpreting and
responding to lessons learned through the MOC performance
evaluation process.
Describe how the performance
improvement evaluation of the MOC will be documented and shared
with key stakeholders.
E. Dissemination of SNP
Quality Performance related to the MOC
Explain, in detail, how the SNP
communicates its quality improvement performance results and
other pertinent information to its multiple stakeholders, which
may include, but not be limited to: SNP leadership, SNP
management groups, SNP boards of directors, SNP personnel &
staff, SNP provider networks, SNP beneficiaries and caregivers,
the general public, and regulatory agencies on a routine basis.
This description must include,
but is not limited to, the scheduled frequency of communications
and the methods for ad hoc communication with the various
stakeholders, such as: a webpage for announcements; printed
newsletters; bulletins; and other announcement mechanisms.
Identify
the individual(s) responsible for communicating performance
updates in a timely manner as described in MOC Element 2A.
|
|
According
to the Paperwork Reduction Act of 1995, no persons are required to
respond to a collection of information unless it displays a valid OMB
control number. The valid OMB control number for this information
collection is 0938-New (CMS-10565). The
current expiration date is TBD. The time required to
complete this information collection is estimated to average 6 hours
per response, including the time to review instructions, search
existing data resources, gather the data needed, and complete and
review the information collection. If you have comments concerning
the accuracy of the time estimate(s) or suggestions for improving
this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA
Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland
21244-1850.