Medicare Special Needs Plan (SNP)

Medicare Special Needs Plan (SNP) created 2/2016   Why we do Model of Care Training Special Needs Plan (SNP) structure for monitoring effectiven...
Author: Terence Holmes
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Medicare Special Needs Plan (SNP)

created 2/2016

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Why we do Model of Care Training Special Needs Plan (SNP) structure for monitoring effectiveness of the MOC



SNP member characteristics



Key elements of SNP MOC



Services and programs included in the MOC



Quiz





The “Model of Care” is a document that ONECare submits to Medicare that describes how ONECare employees and clinicians will work together to successfully deliver care and services to our Special Needs Plan (SNP) members. Medicare mandates that the health plan provides initial training and annual training thereafter, to the providers and employees who deliver care to our Special Needs Plans(SNP) members.





The Model of Care outlines the extra and unique services we offer this very special Medicare population of patients. The Model of Care also includes how we measure the effectiveness of our MOC. It includes reports that we utilize to measure our effectiveness both with implementing the model and outcomes of the care we deliver.







ONECare by Care1st Health Plan Arizona is a full-benefit Dual Eligible Special Needs Plan (D-SNP) ONECare members have a significant burden of chronic disease and disability. The most prevalent conditions are Diabetes, Cardiovascular disease, Hypertension and Respiratory disease. Approximately one third of ONECare members suffer from behavioral health and substance abuse issues and may face challenging social and economic situations.

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Improve health outcomes Improve access to care Improve coordination of care Facilitate smooth transition of care for the patient and clinician Assist with safe management of complex medical, behavioral and/or social concerns for the patient and clinical team

SNP Care Management Staff Structure

Interdisciplinary Care Team (ICT) Care Management

Individualized Care Plans

Integrated Communication Network and Systems

Coordination of SNP Care Structure

Analysis of Effectiveness

Health Risk Assessment

Policies and Procedures

Quality Improvement Program





Care Management/Interdisciplinary Care Team (ICT)- available to all members and includes an initial and ongoing assessment of risks, needs and benefits, and targeted review on member’s needing further assistance accessing services. Health Risk Assessment (HRA) – Assessment completed for each SNP patient; guides the creation of the Individual Care Plan.





Individualized Care Plan (ICP) – Combines patient reported information with clinician information and national prevention guidelines and is the focus of the Care Management Model for each member. Model of Care Implementation – Supported by the sharing of process, systems and information between patient, clinicians, administrative staff and ONECare.







HRA - Outreach to all members occurs within the 1st 90 days of enrollment in order to complete the HRA. The HRA includes a comprehensive assessment of the physical, psychosocial and functional needs of the SNP member and categorizes the member into 3 risk levels including low, moderate or high. HRA’s are repeated annually, or sooner if needed, based on the member’s health needs.









An Interdisciplinary Care Plan is developed by an Interdisciplinary Care Team (ICT) based on the HRA results. The ICT includes health plan staff from multiple departments and may include external individuals such as a social worker, member/family, PCP, behavioral health staff/provider and/or other specialists. The ICP is updated based on the member’s changing needs and may occur monthly, quarterly or more often. The care coordinator (health plan or delegated entity) is responsible for communicating the care plan to the member and providers.







ONECare is a Special Needs Plan for dual eligible (Medicare & Medicaid) members. All ONECare members are assessed by a care coordinator and receive an individualized care plan developed by an interdisciplinary team. The Model of Care defines how we care for our SNP members and how we measure the results.



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A Health Risk Assessment is required for each SNP member? True False TRUE: The HRA is required for all SNP members.



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There is one Individualized Care plan that applies to all SNP members? True False FALSE – Each SNP member has their own care plan, that’s based on their individual health care needs. No two care plans are the same.



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The Interdisciplinary Care Team never includes the member. True False FALSE – The Interdisciplinary Care Team meeting is open to the specific member and at times include the member/caregiver.

Which statement does not describe the SNP Model of Care? a. The MOC is an evidence–based process by which we integrate benefits and coordinate care for SNP members. b. Execution of the Model of Care is supported by systems and processes to share information between the health plan, patients and providers. c. The MOC facilitates the identification of health risks and major changes in the health status of patients with complex care needs d. The MOC is an optional tool to be used for the management of SNP patients. d. The Model of Care requirement is not optional.