generations advantage focus dc (hmo snp) diabetes care ...diabetes care) • to be eligible for...

GENERAL MODEL OF CARE (MOC) TRAINING

Generations Advantage Focus DC (HMO SNP) Diabetes Care

Special Needs Plan

• Special Needs Plans (SNP)

• The Martin’s Point Generations Advantage Focus DCplan

• What a Model of Care is

• The components of the Focus DC model of care• Provider Network

• Care Coordination• HRA: Health Risk Assessments• ICP: Individualized Care Plans• ICT: Interdisciplinary Care Team• TOC: Transitions of Care

• Performance & Health Outcome Measurement

Through this training you will learn about:

What is a Medicare Advantage SNP?• A Special Needs Plan (SNP) is a type of coordinated-

care Medicare Advantage plan designed to providetargeted care and services to individuals with uniqueneeds. They were created as part of the MedicareModernization Act in 2003.

• Types of Special Needs Plans include:• Dual-Eligible or D-SNPs: for individuals with Medicare and Medicaid• Institutional or I-SNPs: for individuals living in institutions• Chronic-Condition or C-SNPs: for individuals with specific conditions

What is Focus DC?• Martin’s Point Generations Advantage Focus DC is a

Chronic-Condition Special Needs Plan (C-SNP)designed for people who have been diagnosed withdiabetes as a chronic or disabling condition (FocusDiabetes Care)

• To be eligible for enrollment in the plan, an individualmust:

• Live in Cumberland County, and• Be Medicare eligible, and• Have a physician’s verification of their diabetes diagnosis as a

chronic or disabling condition• (Does not include individuals considered to be pre-diabetic.)

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Focus DC Plan Design Features• Focus DC augments core primary care services

with disease management programs designed toimprove patient health outcomes and reducehealth care costs. The plan features:– Coordinated care– Smaller patient populations– Close partnership among plan, members, and

providers– Individual care plans– Specialized benefits– Disease/case management services

• Members choose an in-network primary care providerwho manages their care and referrals to in-network specialists and facilities.

• Preauthorization from Generations Advantage is requiredfor some services such as planned inpatient hospital care.

Focus DC Plan Benefit Design Structure

Focus DC Plan Benefit Design StructureOther special benefits include:• $0 copays for many generic prescriptions at pharmacies

with preferred cost-sharing• $0 copay for lab work relating to diabetes• Comprehensive dental services through the

Northeast Delta Dental PPO network

• Free 24-hour nurse hotline• Local customer service (phone or in-person)

• $0 specialist visits for podiatry, endocrinology, mentalhealth and substance use

• 12-month nutrition and dietary program through GoodMeasures at no cost

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What is a Model of Care (MOC)?• A Model of Care (MOC) for a Special Needs Program

(SNP) is a documented plan for identifying andaddressing the unique needs of the plan population

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NCQA evaluates and approves a MOC to ensure the plan meets Medicare requirements

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The MOC document provides the “how to” for administering the Special Needs Program

A Model of Care is required by the Centers for Medical and Medicaid Services (CMS) for Special Needs Plans

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The MOC ensures members receive the care they need

Model of Care - Components


• Provider Network• Performance & Health Outcome

Measurement• Model of Care Training

Care Coordination• Working as an extension of primary care, Focus

DC will help members understand their chroniccondition, follow the treatment plansrecommended by PCPs, take prescribedmedications, and make healthy choices thatimprove the quality of their lives.

Care Coordination

• Care Manager serves as themember’s single point ofcontact for their care and helpscoordinate the efforts of allmembers of a Care Team

• Care Manager guides memberto ensure that care is receivedwhen needed

• Care Manager, NursePractitioner, and MemberServices Representativeintroduce member to new planbenefits and discussindividual health needs

• Lays foundation for targetedcare

Care Coordination

•Coordinated care from anetwork of health careprofessionals who haveexpertise in diabetic care

• Includes PCP, specialists,health educators and coaches,behavior health experts, socialsupports, and more

•Member and Care Teamdevelop a Care Plan withmember’s unique health needsand goals in mind

•Care Plan will help memberstay on track to receivescreenings and specialist carerecommended by the AmericanDiabetes Association

Model of Care - Components• Care Coordination

• HRA: Health Risk Assessments• ICP: Individualized Care Plans• ICT: Interdisciplinary Care Team• TOC: Transitions of Care



Health Risk Assessments (HRAs)• All SNP members receive written notification of the need to

complete an HRA upon enrollment.

• The HRA tool creates an individualized health status andassigns an overall risk score. The HRA measures risk inseveral health areas including, but not limited to:

- Functional, Social, Cognitive, Financial, Behavioral, Environmental Risk

CMS Requirement Per MOC• An initial HRA must be completed within 90 days of enrollment

and annually thereafter• If a member is not willing to complete the HRA or is not willing

to participate in CM there must be documentation of 3attempts in 10 business days and a letter sent to the member within the 90 days or prior to their annual exam

Individualized Care Plans (ICPs)• The Case Manager develops the care plan specific to each member based

upon the assessment and member needs.

• The ICP consists of SMART goals and an intervention plan and provides aframework for monitoring and re-evaluating the member’s progress.

• The ICP is reviewed and revised whenever the Case Manager or ICT feels itis appropriate.

CMS Requirement- Per MOC• All members will have an ICP within 30 days of their HRA/Initial

Assessment and then annually.• If a member refuses to complete an HRA and/or not willing to participate

in care management after attempts within the first 90 days, an ICP will bedeveloped within 30 days. All members will have an ICP within 120 days ofeffective date.

• Initial and annual ICPs are mailed to members.

Interdisciplinary Care Team• Focus DC uses an Interdisciplinary Care Team (ICT)

approach to ensure patients receive the extra guidance,coordinated care, community resources, and specializedbenefits they need to live healthier lives with diabetes. ICTsare coordinated by Focus DC Care Managers and include:– Patients– Primary care providers and staff– Pharmacist and medical director– Other team members as needed:

• Specialty providers such as endocrinologists and podiatrists• Social workers and mental health providers• Family members and community resource groups

Per MOC• Written invitations are sent to the member and primary care

provider to participate in person or by phone. Done minimallyon an annual basis.

Interdisciplinary Care Team Functions

Care Manager– Welcome Visit/Health Risk Assessment– Development of Individual Care Plan with member– Determine whether a member home assessment is needed– Motivational interviewing and self-management support

Community Care Specialist– Assessment of socioeconomic, social, and emotional needs– Patient safety assessments

Primary Care Providers, Specialists, and Staff– Medical expertise, diabetes care, and communication with ICT

Clinical Pharmacist– Medical Therapy Management (MTM)

Medical Director– Supports the Care Manager, Community Care Specialist, and

Pharmacist– Leads weekly case reviews, providing input as needed

Transitions of Care• Coordinated transitions of care:

– Post-discharge support– Follow-up physician visits within seven days of hospitalization– Documentation of post-discharge medication reconciliation

• Appropriate utilization of services:– Reduced hospital admissions– Reduced readmission rates– Reduced emergency room visits

Provider Network• Primary Care Providers: Select Primary Care Providers

in Cumberland County, Maine chosen based on:- Diabetic quality of care- Diabetic health outcomes- Diabetic expertise and experience- Collaborative partnership- Location/member access

• Specialty Providers and Facilities: Focus DCmembers enjoy access to the entire GenerationsAdvantage network of specialists and facilities acrossMaine and New Hampshire.

Care CoordinationWhat is Expected as a Member's PCP

• Follow diabetes-care best practice

• Conduct annual physicals, annual wellness visits

• Conduct complete and accurate diagnosis coding anddocumentation

• Review the care plan when sent and reach out if any concernsor questions

CommunicationWhat is Expected as a Member's PCP

• Most Focus DC member Individual Care Plans will not requirea response, but some will. We expect timely replies, ifrequested.

• We ask Focus DC PCPs to share medical records uponrequest, notify us of any specialist referrals, social/ situationalobstacles, or death of a patient.

• We may need to contact PCP offices with patient concerns orrequests, we ask that PCP offices make best efforts to replywithin 24- 48 hours, or as soon as possible for urgent caremanagement requests.

Care Management What Practices Can Expect

• Notification when your Focus DC patient has enrolled into theFocus DC plan

• Invitations to participate in case reviews withInterdisciplinary Care Teams

• Care coordination support, as needed, for your Focus DCpatientsIncluding but not limited to:

– Transitions of care

– Community resources

– Benefit optimization


• Care coordination• HRA: Health Risk Assessments• ICP: Individualized Care Plans• ICT: Interdisciplinary Care Team• TOC: Transitions of Care

• Provider network• Performance & Health Outcome


Focus DC Goals• Improved patient experience, health outcomes, and cost of

care for people living with diabetes• Monitor key utilization metrics: admissions and readmission• Improved access to care and specialized benefits• Increase member engagement with their primary and specialty

care providers• Increased member and family involvement regarding end-of-

life treatment preferences, living wills, advance directives, etc.• Improving care transitions across health care settings



• Provider network• Performance & Health Outcome

Measurement• Model of Care Training Ö

Questions

For further information, please contact:Susan LyonsHealth Management Clinical Program ManagerMartin’s Point Health Care

[email protected]

generations advantage focus dc (hmo snp) diabetes care ...diabetes care) • to be eligible for...

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