Medicare Model of Care
This webinar provides insights into the Medicare Model of Care, emphasizing the role of Interdisciplinary Team members, care managers, and providers in managing transitions of care for Medicare members. Learn about the background of Special Needs Plans, care management services for Medicare members, and the necessity of ongoing training to comply with regulatory requirements.
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Presentation Transcript
Medicare Model of Care Provider Webinar May 19, 2023 PRV 23.034
Objectives To describe the Medicare Model of Care To understand the requirements of the Medicare Model of Care To understand who are the Interdisciplinary Team (ICT) members and their role in the development of the Plan of Care Understand the role of the care manager and provider in Transitions of Care Food programs for Medicare members 2
WHY ARE WE PROVIDING THIS TRAINING TODAY? Chapter 42 of the Code of Federal Regulations mandates that Special Needs Plans (SNPs) conduct Model of Care (MOC) training for all employees and contracted providers This training must be completed annually This training covers our MetroPlusHealth Advantage Plan and our MetroPlusHealth Medicaid Advantage Plan, UltraCare Both the Medicare Advantage and Medicaid Advantage Plans are D-SNPs 3
BACKGROUND Congress created SNPs in the Medicare Modernization Act of 2003 Special needs plans (SNPs) focus on vulnerable groups of Medicare beneficiaries D-SNP members are individuals who are dually eligible for Managed Medicare with FFS Medicaid A SNP is for individuals who are dually eligible for Medicare and Medicaid Full duals Full duals: individuals who have Medicare benefits and also receive full Medicaid benefits Partial duals Partial duals: individuals who have full Medicare benefits but do not qualify for full Medicaid because of their income. These individuals are eligible for Medicare Advantage but not integrated plans like Medicaid Advantage (UltraCare) The SNP Model of Care (MOC) covers both our MetroPlusHealth Advantage Plan and our Medicaid MetroPlus Ultracare D-SNP 4
CARE MANAGEMENT SERVICES FOR MEDICARE MEMBERS MetroPlusHealth Care Management coordinates services to meet the medical, behavioral, psychosocial, and functional needs of the dual eligible members. MetroPlusHealth Care Managers are either Registered Nurses or Social Workers Medicare Advantage and UltraCare (MAP) members are assigned a Care Manager Members are assessed using the Health Risk Assessment (HRA) for Medicare Advantage and the Uniform Assessment System (UAS-NY) for the UltraCare members Following the assessment an individualized care plan (ICP) is developed with participation of the Member, Care Manager, PCP and others as needed 5
WHO ARE THE INTERDISCIPLINARY TEAM (ICT) MEMBERS? The ICT functions as a multidisciplinary team to support the member to improve the members health conditions. The member is the central focus of the team. The purpose of the ICT is to: Assist the member with care coordination Assist the member with managing transitions of care after an acute care admission Mediate identified barriers to care Facilitate and coordinate the course of treatment prescribed by the PCP While the core of the ICT are the member, care manager, and PCP, others, such as the pharmacist, physical therapist, specialist, etc., can participate as needed 6
WHAT IS A PLAN OF CARE? Care Plans identify member-specific goals that address the member s needs The Integrated Care Plan (ICP) addresses the following: Short and long term goals Issues identified in the annual assessment Gaps in care Medication reconciliation/review Educational needs For MAP, the care plan is called the Person-Centered Service Plan (PCSP) it is more comprehensive than the ICP The PCSP considers other elements such as residential setting and supports The individualized care plans are shared with the member and the provider 7
WHAT IS THE HEALTH RISK ASSESSMENT (HRA)? The Health Risk Assessment (HRA) is an objective tool used to collect information on a beneficiary s health status, health risk factors, social determinants of health, and functions of daily living Social determinants of health questions relate to food insecurity, transportation, homelessness, and utilities Conducted upon enrollment and annually For MAP, the HRA is the Uniform Assessment System of NY (UAS-NY) 8
QUESTIONS ON THE HRA In the past 6 months, have you ever had to go without healthcare because you didn t have a way to get there? Yes No Did you fall in the past 6 months? Yes No Does anyone in your life hurt, threaten, frighten you, or make you feel unsafe? Yes No Prefer not to answer Do you use any of the following: Cane Walker Wheelchair Hospital bed Oxygen Protective Briefs / Pads (Adult diapers) Other ______________________________________________________________________________________________ What is your living situation? I have a steady place to live I have a place to live today, but I am worried about losing it in the future I do not have a steady place to live (temporarily staying with others, in a hotel, shelter, living outside on street, on a beach, in a car, abandoned building, bus or train station, park, other) Are you worried that the place you are living now is making you sick? (i.e. mold, bugs / rodents, water leaks, not enough heat, other) Yes No Other: _____________________________________________________ 9
QUESTIONS ON THE HRA Do you currently receive public assistance (Food Stamps, Meals on Wheels, HEAP, EPIC, public or cash assistance, etc.)? Yes No I do not know In the past year, did you worry that your food could run out before you got money to buy more? Yes No Prefer not to answer In the past year, has the electric, gas, oil, or water company threatened to shut off services to your home? Yes No I do not know Do you smoke cigarettes, vape (e-cigarettes), or use tobacco? Current Former Never Did you get the Influenza Vaccine (Flu Shot) this year? Yes No I do not know Please list your medications (list additional medications of an extra sheet, if applicable): Do you have repeated or ongoing pain? Yes No If yes, start date: ____ _ If yes, where is the pain? __________________________ 10
TRANSITIONS OF CARE (TOC) Upon admission to a hospital, the member s current Plan of Care is faxed to the facility Upon discharge from the hospital, a Care Manager will reach out to the member and: Conduct a TOC assessment (assesses health status and predicts needs once home) Ensure the member s discharge plan is in effect Develop a Plan of Care (POC) Contact the member weekly for up to 30 days Send the POC to the provider of record for feedback, if needed 11
ROLE OF THE PROVIDER Please see your patients for their annual wellness visit Schedule an appointment within 7 days of discharge from the hospital Review medications with your patient Contact the MetroPlusHealth Care Manager for assistance with care coordination Review the member plan of care and submit feedback where applicable 12
THANK YOU! Contact the MetroPlusHealth Care Manager for assistance with care coordination Email: healthpromotion@metroplus.org Tel: 212-908-8445 Additional information available: Provider Website: https://metroplus.org/providers/ Provider Newsletters: https://metroplus.org/providers/provider-newsletters/ Provider Manual https://metroplus.org/providers/provider-tools/ You are our partner in caring for our member! 13
DEFINING SOCIAL DETERMINANTS OF HEALTH According to the U.S. Department of Health and Human Services, social determinants of health (SDOH) are the conditions in the environments where people are born, live, learn, work, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. SDOH can also be grouped into social, economic, and environmental domains. Often, underlying issues, such as SDOH or motivational factors, affect patients daily living and their medical/chronic conditions management. 15
MEDICARE FOOD PROGRAMS Health Bucks Hospital Discharge Meals For eligible MetroPlusHealth Medicare Advantage, and UltraCare (MAP) members Qualifying condition with ICD-10 Code Discharged from the hospital within the last 7 days Qualifying condition(s) Additional screening criteria for dietary needs required Complete a quarterly healthy task Receive $100 of Health Bucks that can be spent at local farmers markets to purchase fresh fruits and vegetables 5 days = 10 meals (lunch and dinner) Members are required to choose one of the following pre-made options: Standard, dialysis, or vegetarian meals All 4 quarters = $400 per year No extensions 17
MEDICARE FOOD PROGRAMS HEALTH BUCKS Overview of Benefit: Overview of Benefit: Members receive $100 of Health Bucks that can be spent at local farmers markets to purchase fresh fruits and vegetables Qualifying Plans: Qualifying Plans: MetroPlusHealth Medicare Advantage, and Ultra Care Qualifying Condition(s): Qualifying Condition(s): Alzheimer s Disease; Autoimmune disorders; Cardiovascular disorders; Chronic heart failure; Chronic disabling mental health conditions; Chronic alcohol and other drug dependance; Chronic lung disorders; Dementia; Diabetes; End stage liver disease; End stage renal disease (ESRD); HIV/AIDS; Kidney Disease; Hyperlipidemia; Malnutrition/Undernutrition; Neurologic disorders; Osteoporosis; Severe hematologic disorders; Stroke Eligibility Requirements: Eligibility Requirements: Complete healthy activity Live in NYC Quarterly benefit, all 4 quarters = $400 per year 18
MEDICARE FOOD PROGRAMS HOSPITAL DISCHARGE (2 X 5) BENEFIT Overview of Benefit: Overview of Benefit: Members receive 5 days worth of pre-made nutritious meals post hospital discharge (10 meals total, lunch and dinner) Qualifying Plans: Qualifying Plans: MetroPlusHealth Medicare Advantage, and Ultra Care Qualifying Condition(s): Qualifying Condition(s): Alzheimer's disease; cancer ; chronic hepatitis B ; hypertension ; chronic obstructive pulmonary disease ; chronic hepatitis C ; coronary heart disease ; heart failure , hyperlipidemia ; kidney disease ; malnutrition ; osteoporosis ; type II diabetes mellitus ; hypertension ; stroke Eligibility Requirements: Eligibility Requirements: Discharged from the hospital within the last 7 days Additional screening criteria for dietary needs Live in NYC Members are required to choose one of the following pre-made options: Standard, dialysis, or vegetarian No extensions 19
Thank You 20
