Title: SNP Training Topic 3: Structure
1SNP Training Topic 3 Structure Process
Measures
- March 27, April 1, 2, 4, 2008
2Objective of SP Measures Training
- Describe the SNP evaluation project NCQA is
executing on behalf of CMS - Explain the intent of the SP Measures
- Determine what type of documentation to provide
- Demonstrate how NCQA will survey the measures.
3Goal for SNP Evaluation Program
- Robust and comprehensive assessment strategy
- Applies to all SNPs
- Responsive to the special in SNP
- Can be implemented soon
4Three-Year Strategy
5Project Time Line Phase 1
- March 14 - Release final SP measures
- April 15 - Release ISS Data Collection Tool
- S P Measures
- April 25 - Release IDSS Data Collection Tool
- HEDIS Measures
- June 30 - HEDIS submissions and SP measures
submissions due to NCQA - Sept 30 - NCQA delivers SNP Assessment Report to
CMS
6Additional Resources
- NCQA SNP Web page www.ncqa.org/snp.aspx
- FAQs (HEDIS)
- Training descriptions schedule
- SP measures
- NCQA Policy Clarification Support (PCS)
- http//app04.ncqa.org/pcs/web/asp/TIL_Client
- Login.asp
- HEDIS Audit information
- http//www.ncqa.org/tabid/204/Default.aspx
7SNP Structure and Process Measures Brett Kay,
Director, Special Needs Plan AssessmentAisha
Pittman, Senior Health Care Analyst
8Overview of the SP Measures
- Start with known entities, raise the bar over
time - Phase one Define and assess desirable structural
characteristics (Evaluate structure and process
requirements through submission of documentation
of policies and procedures - Phase two Assess processes
- Phase Three Assess outcomes
- Apply to all SNP Types (dual, chronic,
institutional)
9SP 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
10Components of the SP Measures
- Standard statement a statement about acceptable
performance or results - Intent statement A sentence that describes the
importance of the SP 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 SP
measure.
11Components of an SP 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
12Data 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 will not require file review
for phase one.
13Components of an SP Measure
- Scope of Review The extent of the organizations
services evaluated during an NCQA survey. Scope
of review may vary - Look-back period The period of time for which
NCQA evaluates an organizations documentation to
assess performance against an element - Explanation Guidance for demonstrating
performance against the element - Example Descriptive information illustrating
performance against an elements requirements.
Examples are for guidance and are not intended to
be all-inclusive
14SNP 1 Complex Case Management
15SNP 1 Complex Case Management
- The organization helps members with multiple or
complex conditions to obtain access to care and
services and coordinates their care - NCQA Definition Complex Case Management
- The 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
16SNP 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.
17SNP 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 all members in CM will
receive 100 for this element - What conditions qualify for entry into CM
program? - NCQA is not prescriptive. It is up to the SNP to
design a program appropriate for its population.
18SNP 1 Element A Examples
- Documentation 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 members prognosis cost and
utilization data catastrophic pharmacy claims
disability claims and aggregate claims exceeding
certain thresholds.
19SNP 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
20SNP 1 Element B FAQs
- Does a SNP have to show all 3 data sources
(documented processes, reports, materials) to
receive credit? - SNPs only need to show as many data sources as
are needed to demonstrate compliance with the
element. For example, promotional materials the
SNP uses to inform members, providers and others
about their CM programs may satisfy some of the
requirements - 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
21SNP 1 Element B Examples
- Documentation may include
- Identify certain disease state or conditions,
certain diagnoses or critical events, and
indicators of the members ability to manage
his/her condition and pharmacy or lab values that
confirm a lack of control that automatically make
the member eligible for case management - 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 - Members showing a lack of progress with
stabilizing his/her condition, the inability to
manage co-morbidities or declines in health
status
22SNP 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
23SNP 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
24SNP 1 Element C Examples
- Documentation may include
- For Factor 1
- 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 members 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 - For Factors 2 and 3
- 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
25SNP 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
26SNP 1 Element D FAQs
- What if a plan automatically enrolls all members
in CM? - Plans that auto-enroll all members in CM will
receive 100 for this element
27SNP 1 Element E
- Providing Members With Information How does the
SNP get information to members - How to use the services
- How members become eligible to participate
- How to opt in or opt out
28SNP 1 Element E
- What type of data sources is NCQA looking for?
- Plans can use the scripts and program information
they provide to members to satisfy the
requirements - 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
29SNP 1 Element F
- Case Management Process
- Members 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
30SNP 1 Element F (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
31SNP 1 Element F FAQs
- Can Plans use screen shots from a computerized
questionnaire to show compliance with this
element? - Yes, provided the screen shots display the fields
with the relevant questions related to the
factors
32SNP 1 Element F Examples
- Evidence that addresses requirements in each of
the fourteen factors may consist of - Policies and procedures which delineate the case
managers 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.
33SNP 1 Element F (cont.)
- Key items in the factors
- Health status
- Clinical history
- ADLs
- Mental health status
- Life planning
- Cultural and linguistic needs
- Caregiver resources
- Benefits
- Case management plan and goals
- Barriers
- Follow-up schedule
- Self-management plan
- Assessing progress
34SNP 1 Element G
- Informing and Educating Practitioners
- Instructions on how to use CM services
- How the organization works with a practitioners
patients in the program - must have a documented process for providing
practitioners with information that includes
instructions on how to use the CM services
35SNP 1 Element G FAQs
- Does the plan have to do all of the items in the
examples section to get credit? - The examples are meant to provide guidance and
are not all-inclusive
36SNP 2 Improving Member Satisfaction
37SNP 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
38SNP 2 Element A FAQs
- Does the member satisfaction apply only to the
SNPs 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. - IF SNPs have CAHPS data, that would satisfy this
element in place of analyzing complaints and
appeals
39SNP 2 Element B
- Opportunities for Improvement
- Plans must review their data and determine how
best to improve - Identify opportunities
40SNP 2 Element B FAQs
- What if no opportunities for improvement are
identified? - If no opportunities are identified in the SNPs
analysis, and NCQA surveyors agree with this
conclusion, the element is scored NA. - Do SNPs have to show improvement based on the
opportunities identified? - For phase one (2008), plans are not required to
demonstrate they have taken action on the
identified opportunities - NCQA anticipates required actions to be taken in
for review in subsequent years
41SNP 3 Clinical Quality Improvements
42SNP 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 - 1st step in a phased approachShow areas for
improvement - Next year and beyondadd steps to require plans
to demonstrate actual clinical improvements
43SNP 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 must show the areas they have identified
for improvement, but are not required to
demonstrate clinical improvements - NCQA anticipates adding steps to this measure to
require plans to demonstrate actual clinical
improvements in later phases of the program.
44Additional Resources
45Training Education
- Five training topic areas, focus is on content
and data submission - Introduction to NCQA HEDIS
- SNP Subset of HEDIS Measures
- Interactive Data Submission System (IDSS)
- Structure Process Measures
- Interactive Survey System (ISS)
46NCQA Policy Clarification Support (PCS)
- Web address
- http//app04.ncqa.org/pcs/web/asp/TIL_ClientLogin
.asp - Link from SNP Web page
- www.ncqa.org/snp.aspx
47PCS (contd)
- 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
48PCS (contd)
- Menu options under Standard/Measures
- If SNP HEDIS was selected
- (COL) Colorectal Cancer Screening
- (GSO) Glaucoma Screening in Older Adults
- (SPR) Use of Spirometry Testing in the Assessment
and Diagnosis of COPD - (PCE) Pharmacotherapy 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
- (BCR) Board Certification
- Other
49PCS (contd)
- 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
- Other
50Contacts
- Brett KayDirector, SNP Assessment202-955-1722k
ay_at_ncqa.orgCasandra MonroeAssistant Director,
SNP Assessment202-955-5136monroe_at_ncqa.org
51