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Model of Care Elements
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1. Description of the plan-specific Target
Population (based on target population of full duals as defined by the State)
The plan’s response to Element #1 (Description of the Plan-specific Target Population)
must include all Virginia-specific
sub-populations of dual eligibles as follows:
a. Individuals
enrolled in the Elderly or Disabled with Consumer Direction (EDCD) waiver;
b. Individuals
with intellectual/developmental disabilities;
c. Individuals
with cognitive or memory problems (e.g., dementia and traumatic brain
injury);
d. Individuals
with physical or sensory disabilities;
e. Individuals
residing in nursing facilities;
f. Individuals
with serious and persistent mental illnesses;
g. Individuals
with end stage renal disease,
h. Individuals
with complex or multiple chronic conditions; and
i. Individuals who have no reported medical, behavioral
health, or long-term service and support (LTSS) needs but may have needs in
the future.
Responses to the Model of Care section should take into
account the fact that many enrolled individuals will have co-occurring
conditions and could be included in more than one sub-population. Populations identified in items a – h are
also included as “Vulnerable Subpopulations” in Element #10.
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2. Measurable Goals
a.
Describe the specific goals including:
1. Improving access to essential services such
as medical, mental health, and social services
2. Improving access to affordable care
3. Improving coordination of care through an
identified point of contact (e.g., gatekeeper)
4. Improving seamless transitions of care
across healthcare settings, providers, and health services
5. Improving access to preventive health
services
6. Assuring appropriate utilization of
services
7. Improving beneficiary health outcomes
(specify organization selected health outcome measures)
b.
Describe the goals as measurable outcomes and indicate how the
organization will know when goals are met
c.
Discuss actions the organization will take if goals are not met in the
expected time frame
The state has no further requirements beyond those
listed above in Element # 2.
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3. Staff Structure and Care Management Roles
a.
Identify the specific employed or contracted staff to perform administrative
functions (e.g., process enrollments, verify eligibility, process claims,
etc.)
b.
Identify the specific employed or contracted staff to perform clinical
functions (e.g., coordinate care management, provide clinical care,
educate beneficiaries on self-management techniques, consult on pharmacy
issues, counsel on drug dependence rehab strategies, etc.)
c.
Identify the specific employed or contracted staff to perform administrative
and clinical oversight functions (e.g., verifies licensing and
competency, reviews encounter data for appropriateness and timeliness of
services, reviews pharmacy claims and utilization data for appropriateness,
assures provider use of clinical practice guidelines, etc.)
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4. Interdisciplinary Care Team (ICT)
a.
Describe the composition of the ICT and how the organization determined
the membership
b.
Describe how the organization
will facilitate the participation of the beneficiary whenever feasible
c. Describe
how the ICT will operate and communicate (e.g., frequency of meetings, documentation of proceedings and retention of
records, notification about ICT meetings, dissemination of ICT reports to all
stakeholders, etc.)
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5. Provider Network having Specialized
Expertise and Use of Clinical Practice Guidelines and Protocols
a. Describe the specialized
expertise in the organization’s provider
network that corresponds to the target population including facilities and
providers (e.g., medical specialists, mental health specialists, dialysis
facilities, specialty outpatient clinics, etc.)
b.
Describe how
the organization determined that its network facilities and providers were
actively licensed and competent
c. Describe who determines which services beneficiaries will receive
(e.g., is there a gatekeeper, and if not, how is the beneficiary connected to
the appropriate service provider, etc.)
d.
Describe how
the provider network coordinates with
the ICT and the beneficiary to deliver specialized services (e.g., how care
needs are communicated to all stakeholders, which personnel assures follow-up
is scheduled and performed, how it assures that specialized services are
delivered to the beneficiary in a timely and quality way, how reports on services
delivered are shared with the plan and ICT for maintenance of a complete
beneficiary record and incorporation into the care plan, how services are
delivered across care settings and providers, etc.)
e. Describe how the organization assures
that providers use evidence-based clinical practice guidelines and nationally
recognized protocols (e.g., review of medical records, pharmacy
records, medical specialist reports, audio/video-conferencing to discuss
protocols and clinical guidelines, written protocols providers send to the
organization’s Medical Director for review, etc.)
The state has no further requirements beyond those
listed above in Element # 5.
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6. Model of Care Training for Personnel and Provider Network
a. Describe how
the organization conducted initial and annual model of care training
including training strategies and content (e.g., printed instructional
materials, face-to-face training, web-based instruction,
audio/video-conferencing, etc.)
b.
Describe how the organization assures and documents
completion of training by the employed and contracted personnel (e.g.,
attendee lists, results of testing, web-based attendance confirmation,
electronic training record, etc.)
c.
Describe who
the organization identified as
personnel responsible for oversight of
the model of care training
d.
Describe what
actions the organization will take
when the required model of care training has not been completed (e.g.,
contract evaluation mechanism, follow-up communication to
personnel/providers, incentives for training completion, etc.)
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7. Health Risk Assessment
a. Describe
the health risk assessment tool the organization uses to identify the
specialized needs of its beneficiaries (e.g., identifies medical,
psychosocial, functional, and cognitive needs, medical and mental health
history, etc.)
b. Describe
when and how the initial health risk
assessment and annual reassessment is conducted for each beneficiary (e.g.,
initial assessment upon enrollment, annual reassessment within one year of
last assessment; conducted by phone interview, face-to-face, written
form completed by beneficiary, etc.)
c.
Describe the personnel who review, analyze,
and stratify health care needs (e.g.,
professionally knowledgeable and credentialed such as physicians, nurses,
restorative therapist, pharmacist, psychologist, etc.)
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8.
Individualized Care Plan
a. Describe which personnel develops the individualized plan of care and how the
beneficiary is involved in its development as feasible
b. Describe the essential
elements incorporated in the plan of care (e.g., results of health risk
assessment, goals/objectives, specific services and benefits, outcome
measures, preferences for care, add-on benefits and services for vulnerable
beneficiaries such as disabled or those near the end-of-life, etc.)
c.
Describe the
personnel who review the care plan and how frequently the plan of care is reviewed and revised (e.g.,
developed by the interdisciplinary care team (ICT), beneficiary whenever
feasible, and other pertinent specialists required by the beneficiary’s
health needs; reviewed and revised annually and as a change in health status
is identified, etc.)
d.
Describe how the plan of care is documented and where
the documentation is maintained (e.g., accessible to interdisciplinary team,
provider network, and beneficiary either in original form or copies;
maintained in accordance with industry practices such as preserved from
destruction, secured for privacy and confidentiality, etc.)
e.
Describe how the plan of care and any care plan
revisions are communicated to the beneficiary, ICT, organization, and
pertinent network providers.
f. Describe how the organization will ensure that plans
of care for all individuals who are enrolled in the program at the time of
the program’s launch are conducted within 90 days of enrollment. Participating
Plans must honor all existing plans of care and prior authorizations (PAs)
until the authorizations ends or 180 days from enrollment, whichever is
sooner. For EDCD Waiver participants, the plan of care must be
developed and implemented by the Participating Plan no later than the end
date of any existing PA.
g. Describe
how the organization will ensure that plans of care for new enrollees who enter
the Demonstration after the
program’s launch are conducted within the following timeframes:
h. The plan shall develop a POC for each individual
enrolled in the plan. The POC will be
tailored to individual needs, based on the plans method of stratification.
The POC shall be updated and agreed to by the individual annually or upon
reassessment resulting from a health status change.
1. Describe the method of stratification, the
person-centered and culturally competent POC development process, and how its
POC development process will incorporate and not duplicate Targeted Case
Management.
2. Describe how information from the Uniform Assessment
Instrument and LOC will be incorporated into the plan of care for individuals
in the EDCD Waiver. [3]
3.
Describe the
organization’s process for obtaining nursing facility MDS data and how it
will be incorporated into the POC.
4.
Describe how
the organization will ensure that individuals in nursing facilities who wish
to move to the community will be referred to the Money Follows the Person
Program.
5.
Describe how
the POC will address health, safety (including minimizing risk), and welfare
of the participant.
i.
In addition to
SNP Model of Care Element 8(b) listed above, describe the process the organization will use to include the following
elements in the POC:
1.
Prioritized list of concerns, needs, and strengths;
2.
Attainable goals and outcome measures with target
dates selected by the individual and/or caregiver;
3.
Strategies and actions, including interventions and
services to be implemented and the person(s)/providers responsible for
specific interventions/services and their frequency;
4.
Progress noting success, barriers or obstacles;
5.
Enrollee’s informal support network and services;
6.
Back up plans as appropriate (for EDCD Waiver
participants using personal care and respite services) in the event that the
scheduled provider(s) is unable to provide services;
7.
Determined need and plan to access community
resources and non-covered services;
8.
Enrollee choice of services (including
consumer-direction) and service providers; and
j. Describe how the organization will ensure that
reassessments and plan of care reviews are conducted:
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9.
Communication Network
a. Describe the organization’s structure for a communication network (e.g., web-based network,
audio-conferencing, face-to-face meetings, etc.)
b. Describe how the communication network connects the
plan, providers, beneficiaries, public, and regulatory agencies
c.
Describe how
the organization preserves aspects of
communication as evidence of care (e.g., recordings, written minutes,
newsletters, interactive web sites, etc.)
d.
Describe the
personnel having oversight
responsibility for monitoring and evaluating communication effectiveness
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10.
Care Management for the Most
Vulnerable Subpopulations
a. Describe how the organization identifies its most
vulnerable beneficiaries
b. Describe the add-on services and benefits the
organization delivers to its most vulnerable beneficiaries
For Element 10(a) “Vulnerable
Subpopulations” shall include, at a minimum:
a. Individuals
enrolled in the Elderly or Disabled with Consumer Direction (EDCD) Waiver;
b. Individuals
with intellectual/developmental disabilities;
c. Individuals
with cognitive or memory problems (e.g., dementia and traumatic brain
injury);
d. Individuals
with physical or sensory disabilities;
e. Individuals
residing in nursing facilities;
f. Individuals
with serious and persistent mental illnesses;
g. Individuals
with end stage renal disease; and
h. Individuals
with complex or multiple chronic conditions.
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11. Performance and Health Outcome Measurement
a. Describe how the organization will collect, analyze,
report, and act on to evaluate the model of care (e.g., specific data
sources, specific performance and outcome measures, etc.)
b. Describe who will
collect, analyze, report, and act on data to evaluate the model of care
(e.g., internal quality specialists, contracted consultants, etc.)
c.
Describe how
the organization will use the
analyzed results of the performance measures to improve the model of care
(e.g., internal committee, other
structured mechanism, etc.)
d. Describe how
the evaluation of the model of care will be documented and preserved as
evidence of the effectiveness of the model of care (e.g., electronic
or print copies of its evaluation process, etc.)
e.
Describe the
personnel having oversight
responsibility for monitoring and evaluating the model of care effectiveness
(e.g., quality assurance specialist, consultant with quality expertise, etc.)
f.
Describe how the organization will communicate
improvements in the model of care to all stakeholders (e.g., a webpage for
announcements, printed newsletters, bulletins, announcements, etc.)
Participating plans will be
required to report on quality indicators to allow an evaluation of the impact
on quality of care for enrollees. The CMS-required Core Quality Performance
Measures (as determined) and the EDCD Waiver Performance Measures. Plans must
also adhere to Medicaid managed care regulatory standards in 42 CFR
438.240. All performance measures are subject to change per final three-way
contract terms.
Plans will work with DMAS to
monitor elements of the EDCD Waiver quality improvement strategy which must
address assurances as required by CMS, including: (i) service plan, (ii)
qualified providers, (iii) financial authority, (iv) health, safety, and
welfare, (v) level of care; and (vi) administrative authority.
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12. Additional Element #1:
Hospital and Nursing Facility Transition Programs
Describe the process, systems, and goals in detail for
ensuring smooth transitions to and from hospitals, nursing facilities and the
community, including:
a. How the plan will ensure that communication of an
admission or discharge will be conveyed to the PCP, care manager and home and
community-based providers within 24 hours;
b. How the plan will ensure that admissions and lengths
of stay are appropriate to the individual’s needs;
c. How the plan will ensure that there is timely and
adequate discharge planning and medication reconciliation;
d. How the plan will work to reduce the need for
hospital transfers and emergency room use; and
e. How the plan will work with nursing facility staff
(including obtaining MDS Section Q data), hospital staff, and the state
Long-Term Care Ombudsman to facilitate transitions to the community. This
shall include how individuals are referred to local contact agencies in order
to facilitate transitions and are linked with other community resources that
provide support to individuals and their families/caregivers, such as Centers
for Independent Living, Community Services Boards, and local Area Agencies on
Aging, and MFP.
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The plan shall describe
how it will provide care management functions for all enrollees.
At a minimum, all enrollees shall have access to the
following supports:
1.
A single, toll-free point of contact for all
questions;
2.
Develop, maintain and monitor the POC.
3.
Assurance that referrals result in timely
appointments;
4.
Communication and education regarding available
services and community resources; and
5.
Assistance developing self-management skills to
effectively access and use services.
1.
Ensure that individuals receive needed medical and
behavioral health services, preventative services, medications, LTSS, social
services and enhanced benefits; this includes setting up appointments,
in-person contacts as appropriate, strong working relationships between care
managers and physicians; evidence-based patient education programs, and
arranging transportation as needed.
2.
Monitor functional and health status;
3.
Ensure seamless transitions of care across
specialties and settings;
4.
Ensure that individuals with disabilities have
effective communication with health care providers and participate in making
decisions with respect to treatment options;
5.
Connect individuals to services that promote
community living and help avoid premature or unnecessary nursing facility
placements;
6. Coordinate with social service agencies (e.g.
local departments of health, social services, Area Agencies on Aging, and
Community Services Boards) and refer enrollees to state, local, and other
community resources; and
7.
Work with nursing facilities to include management of
chronic conditions, medication optimization, prevention of falls and pressure
ulcers, and coordination of services beyond the scope of the NF benefit.
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14. Additional Element #3: Partnering
with Community Care Management Providers
Describe any innovative
arrangements the plan will use to provide care management. Plans are strongly
encouraged to partner and/or contract with entities that currently perform
care management and offer support services to individuals eligible for the
Demonstration. This flexibility
includes the use of innovations such as health homes, sub-capitation, shared
savings, and performance incentives. Entities can include, but are not
limited to Community Services Boards (CSBs), adult day care centers, and
nursing facilities.
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