2. CarePoint Health Plans is an insurance
company that shares ownership with Bayonne
Medical Center, Christ Hospital and Hoboken
University Medical Center
CarePoint is currently licensed in Hudson
County
CarePoint Health Plans has a contract with the
Centers for Medicare and Medicaid Services
(CMS) to offer an MAPD plan and an I-SNP
plan
3. A Medicare Advantage plan combines traditional
Medicare A & B
Medicare Advantage (or Part C) is managed care
Medicare
The coverage is provided by a private (non-
governmental) insurance company
Anyone who has Medicare A & B, lives in the
coverage area, and does NOT have End-Stage
Renal Disease is also eligible for a Medicare
Advantage plan
Medicare Advantage plans are usually offered
with Part D (prescription drug) coverage as well
and are known as MAPD plans.
4. Prescription drugs are covered under
Medicare Part D
Most Medicare Advantage plans include
prescription drug coverage under Part D – if
the plan offers Part D, a member must get
their coverage under it
A Medicare Advantage plan that offers Part D
is called an MAPD plan
5. A Special Needs Plan is a Medicare plan that limits
enrollment to members with specific diseases or
characteristics and tailors benefits to best meet their
needs
An I-SNP is an Institutional Special Needs Plan
This is a Medicare managed care plan for individuals
who, for 90 days or longer, have had or are expected
to need LTC SNF, LTC NF, SNF/NF, ICF/MR or
inpatient psychiatric level of care. Individuals in the
community may be enrolled if they also require the
institutional level of care.
I-SNP eligibility must be verified independently, using
the State-approved assessment tool, such as the
PASRR, OASIS, MDS, and documentation from the
individual’s physician.
6. Premiums and benefits differ between
CarePoint’s MAPD and I-SNP.
◦ CarePoint Advantage (MAPD PPO) $0 additional
premium (still pay Part B premium)
◦ CarePoint Guardian (I-SNP PPO) $37 monthly
premium
Refer to the Summary of Benefits and
Evidence of Coverage for differences between
traditional Medicare, CarePoint Advantage
and CarePoint Guardian
7. Imperative to adhere to all CMS Marketing
Guidelines
Potential members MUST request an appointment
– NO REFERRALS and NO SOLICITATION
Potential members may be identified:
◦ At Sales & Marketing and Educational events
◦ By approaching a clearly-identified Sales & Marketing
representative
◦ By contacting a Sales & Marketing representative as a
result of seeing approved marketing material or at the
suggestion of another individual
◦ I-SNP eligibility MUST be verified BEFORE a Sales &
Marketing meeting can be scheduled with the individual
8. A Medicare Advantage plan can be either an HMO
or a PPO – currently, CarePoint’s plans are PPOs
The Primary Care Physician must be in-network
in both types of plans
Both HMO and PPO must have appropriate access
to primary care and specialists in-network
“Network Adequacy” includes: number and
specialty of providers, distance and travel time to
providers within the community the Plan serves
9. Provider network includes primary care and specialist
physicians, mid-level providers, allied health
practitioners, tertiary care facilities, lab, x-ray, home
health, transportation and others
Often, additional providers are contracted for services
not available within the network (example: transplant
surgery, cardiac surgery)
Occasionally an out-of-network provider may be
contracted for a single patient and/or a single case
All network providers are subject to the Plan’s
Credentialing process and Quality measures and,
All staff and providers will participate in orientation to
this model of care on a yearly basis
10. In an HMO the member receives all care in-
network, and referrals are usually required
In a PPO the member may go out-of-network for
care – the cost-sharing is usually higher. For
CarePoint Advantage the member has a 30%
cost-share for most out-of-network services
PPOs do not require referrals
In both types of plans approval, also known as
Prior Authorization, for certain types of tests is
often required (example: CT scans, MRI,
endoscopy)
11. Improve care through:
◦ Improving access to care
Network primary care and specialty physicians
including Behavioral Health
Assess health care needs and respond
Access to additional resources
Maintenance of health care coverage
◦ Improving coordination of care
Utilize care managers, nurse practitioners
Provide clear explanation of available benefits and how
to access
12. Provide care that is coordinated across settings
Improve member health with best practice
preventive health services
Make certain members receive:
◦ The right care
◦ In the right setting
◦ In the right amount
◦ At the right time
◦ For the right member
Monitor member health and provider practices to
assure improvement in positive health outcomes
13. Owned by the same owners as the hospitals
Administrative staff roles and responsibilities
◦ Executive management
◦ Provider network and relations
◦ Compliance
◦ Finance
◦ Sales & Marketing
◦ Customer service
◦ Claims payment
◦ Information technology
◦ Human resources
14. Clinical staff roles and responsibilities
◦ Chief medical officer
◦ Director of Quality
◦ Director of Care Management
Case & Disease Management
Utilization review
◦ Appeals and Grievances
◦ Pharmacy management
15. Patient care is provided primarily by
CarePoint’s network of providers
Members receive care across the entire
spectrum of settings, from outpatient to
observation, inpatient, rehabilitation and
skilled nursing facility.
Because a Medicare Advantage plan is offered
by a managed care organization, care is
coordinated for the member in all settings.
16. Care coordination is accomplished using a
variety of resources:
◦ Physicians and other providers
◦ Care and Case Managers
◦ Mid-level providers (e.g. nurse practitioners)
◦ Nurses
◦ Discharge planners
◦ Home health care agencies
◦ Social workers
◦ Area Agencies on Aging
◦ Community- and faith-based organizations
◦ Others
17. Communication
◦ A critical component of the coordination of care
◦ Include all stakeholders
◦ Coordinate care between member, family, members
of care team
◦ Provide information using multiple forms of media
including mail, e-mail, Web, member and provider
portals, phone, fax, face to face meetings, video
conferencing, member handbook, member
newsletter, provider manual, information packages,
provider profiles, policies & procedures, inter-
disciplinary care team meetings
18. CarePoint provides a robust IT care management system to
track:
◦ Member health
◦ Quality of care
◦ Member plans of care
◦ Medical/surgical, behavioral, radiology, laboratory and pharmacy
encounter and claims information
◦ Metrics to support the above measures plus HEDIS and others
Information is shared with members of the integrated
health care system to improve:
◦ Quality of care
◦ Access to care
◦ Overall health outcomes
◦ Efficiency
◦ Productivity
19. Guided by the members’ health status, CarePoint
may provide management in the form of:
◦ Automated information provided by mail, e-mail or
phone
◦ Individualized information provided by phone by a care
manager
◦ Personalized visits by a mid-level provider
This information may relate to a member’s:
◦ Medications
◦ Upcoming appointments for provider visits, testing or
procedures
◦ Prescription order updates
◦ Recommendations for health care management.
21. Patient Centered Care
Manage care across the continuum using
◦ Primary Care Physicians
◦ Mid-level providers
◦ Coordinate community-based/faith-based services
◦ Leverage additional resources
Pro-actively manage population and
individual care
◦ Identify care needs and gaps in care early and
intervene before the member’s condition worsens
Focus on the member/family experience
22. All members (MAPD & I-SNP) will complete a
Health Risk Assessment (HRA) upon enrollment;
assistance will be provided to those who are
unable to do this on their own
The HRA will be incorporated in the Plan’s
medical management system to generate a
Clinical Risk Assessment
This Clinical Risk Assessment will be used by the
Plan to provide the most appropriate care
management resources for the member
As additional diagnostic and pharmacy data is
obtained about the member, this clinical risk
assessment will be refined using the Johns
Hopkins ACG System
23. The Health Risk Assessment contains questions
regarding
◦ Family history
◦ Personal health status
◦ Activities of daily living (ADLs)
◦ Medications
◦ Use of/Need for special services
◦ Use of preventive services
◦ Pain
◦ Fear of falling
◦ Mental health and cognitive function
◦ Nutrition/Exercise/Health habits
◦ Tobacco/Substance use and abuse
◦ Social supports
◦ Quality of life
24. Clinical Risk Assessment
◦ Medical Care Management staff at CarePoint will use the
information to:
Create a Plan of Care based on nationally-accepted Clinical
Practice Guidelines and coordinate this Plan of Care with the
member’s primary care physicians
Analyze the member’s care history to identify gaps in care
and upcoming needs (barriers to care and interventions)
Determine appropriate care management tools for member –
phone calls, written material by mail, e-mail reminders,
assignment of mid-level provider for members at higher risk
Members must be given the option to not participate in care
management – the Plan will continue to monitor their health
status and they may opt-in at any time
25. Member engagement will be promoted with a variety of
methods including:
Motivational interviewing (“What’s important to you? What
would it mean to you to get it? What would it mean if you
didn’t?”)
Direct contact from Care Management staff
Culturally appropriate health information available in a variety
of media
Incentives when legally permissible and appropriate
26. Empower practitioners
◦ Information on best practices
◦ Identification of gaps in care
◦ Objective data on individual practice versus peers
◦ Provide clinical management tools
◦ Emphasis on preventive care
28. Mid-Level Providers (NP)
Deploy across continuum of care
Improve access to care
Refer members to Primary Care Physician
office
Provide efficient, evidence-based care
Enhance provider-member engagement,
communication and productivity
Coordinate resources
30. The I-SNP Model of Care introduces
additional resources to care for
institutionalized and institutional-equivalent
members, and most importantly, those most
vulnerable (multiple chronic conditions
and/or medications, dual diagnosis, end of
life) identified by Care Management and the
team of practitioners
◦ Inter-Disciplinary Care Team
◦ INTERACT II care management method and tools
◦ Enhanced care coordination
31. Inter-Disciplinary Care Team (IDCT)
◦ All I-SNP members will have an IDCT comprising
representatives of the coordinated care team
◦ New members of the IDCT will be included to address
developments in the member’s care needs
◦ Member and family participation is actively encouraged.
Invitations and meeting summary letters are sent
◦ The IDCT meets regularly, updates the Plan of Care as
necessary, and may additionally meet should there be a
change in condition of the member
◦ Best-Practice care will be coordinated, and will include
the use of IT infrastructure and prior-authorization
32. Additional components of model of care
◦ Care providers use INTERACT II
Empowers everyone in the institution to improve the
quality of care
Clinical and educational tools and strategies to
manage changes in resident condition
Improve quality with early identification, assessment,
documentation and communication
Resources to manage end of life care as well
Examples of INTERACT II clinical tools follow:
STOP AND WATCH and the SBAR documentation tool
33. INTERACT Early Warning Tool – STOP AND WATCH
Seems different than usual
Talks or communicates less than usual
Overall needs more help than usual
Participated in activities less than usual
Ate less than usual (Not because of dislike of food)
N
Drank less than usual
Weight change
Agitated or nervous more than usual
Tired, weak, confused, or drowsy
Change in skin color or condition
Help with walking, transferring, toileting more than usual
34. INTERACT II “PROGRESS NOTE” - SBAR
Physician/NP/PA Communication and Progress Note
For New Symptoms, Signs and Other Changes in Condition
Before Calling MD/NP/PA:
Evaluate the resident and complete the SBAR form (use
“N/A” for not applicable)
Check VS: BP, pulse, respiratory rate, temperature, pulse
ox, and/or finger stick glucose if indicated
Review chart: recent progress notes, labs, orders
Review relevant INTERACT II Care Path or Acute Change
in Status File Card
Have relevant information available when reporting (i.e.
resident chart, vital signs, advanced directives such as
DNR and other care limiting orders, allergies, medication
list)
35. SBAR DETAILS
S SITUATION
The symptom/sign/change I’m calling about is _______________________________________________________
____________________________________________________________________________________________
This started___________________________________________________________________________________
This has gotten (circle one) worse/better/stayed the same since it started
Things that make the condition worse are ___________________________________________________________
Things that make the condition better are ___________________________________________________________
Other things that have occurred with this change are __________________________________________________
B BACKGROUND
Primary diagnosis and/or reason resident is at the nursing home _________________________________________
Pertinent history (e.g. recent falls,fever, decreased intake, pain, SOB, other) ________________________________
_____________________________________________________________________________________________
Vital signs BP_________/__________ HR ________________ RR ________________ Temp ________________
Pulse Oximetry ____________% On RA___________on O2 at ______________L/min via___________ (NC, mask)
Change in function or mobility ____________________________________________________________________
Medication changes or new orders in the last two weeks _______________________________________________
Mental status changes (e.g. confusion/agitation/lethargy) ______________________________________________
GI/GU changes (circle) (e.g. nausea/vomiting/diarrhea/impaction/distension/decreased urinary output/other)
Pain level/location ______________________________________________________________________________
Change in intake/hydration _______________________________________________________________________
Change in skin or wound status ___________________________________________________________________
Labs ________________________________________________________________________________________
Advance directives (circle) (Full code, DNR, DNI, DNH, other, not documented)
Allergies __________________________________ Any other data ______________________________________
A ASSESSMENT (RN) OR APPEARANCE (LPN)
(For RNs): What do you think is going on with the resident? (e.g. cardiac, infection, respiratory, urinary, dehydration,
mental status change?) I think that the problem may be ____________________________________________-OR
I am not sure of what the problem is, but there had been an acute change in condition.
(For LPNs): The resident appears (e.g. SOB, in pain, more confused) _____________________________________
R REQUEST
I suggest or request (check all that apply):
Provider visit (MD/NP/PA) Monitor vital signs and observe
Lab work, x-rays, EKG, other tests Change in current orders _______________________
IV or SC fluids New orders __________________________________
Other (specify) ________________________ Transfer to the hospital
Staff name ____________________________________________________________________________RN/LPN
Reported to: Name ____________________________(MD/NP/PA) Date____/____/____ Time________a.m./p.m.
If to MD/NP/PA, communicated by: Phone In person
Resident name _______________________________________________________________________________
36. INTERACT II tools at the bedside for early
identification & assessment
Care Paths
◦ Dehydration
◦ Fever
◦ Mental status change
◦ Symptoms of CHF
◦ Symptoms of lower respiratory tract infection
◦ Symptoms of UTI
37. Value-added benefits
◦ Nursing facilities will have free WiFi, resident e-
mail, Internet café
◦ Wanderguard ® - to identify individuals who have
wandered from allowed areas
◦ Delayed egress magnetic locking doors – to prevent
elopement
◦ Pet therapy
◦ Video-conferencing for members and their families
38. Care Transitions
◦ Members in MAPD & I-SNP will be managed across
the continuum of care
◦ Mid-level providers will manage transitions with the
members’ physicians to assure continuity of care,
medication reconciliation, and adherence to the
Plan of Care
40. Bi-directional exchange of information
Expanded population stratification
Pro-active care management and gap analysis
Analytics
Robust clinical metrics
◦ Based on HEDIS/NCQA -> 5-Star
◦ Provider profiling and appropriate corrective action
42. Quality – Making sure we’re doing it right!
MAPD & I-SNP Quality Management Steering
Committee
◦ Supported by:
Medical Care Management Committee
Medical Standards Committee
Grievance & Appeal Committee
Credentialing Committee
Pharmacy & Therapeutics Committee
◦ Coordinated with Compliance Committee
Quality indicators measure process and outcomes of
care.
Quality indicators, overall and by provider, will be
monitored, tracked and trended and compared to
benchmarks and goals.
43. Indicators and Goals:
◦ Provider Access Standards – 90% for all providers
◦ Appointment Availability Standards – 90% for all providers
◦ % of members who selected a PCP
◦ % of MDS completed in 30 days – 100%
◦ % of Plans of care completed within 5 days of transition –
100%
◦ % of members who received flu and pneumovax vaccine –
increase by 5-10%
◦ HEDIS® Effectiveness of Care measures – meet 50th
percentile of NCQA
◦ % of avoidable re-admissions – reduce by 3-5%
◦ % of inappropriate ER utilization – reduce by 3-5%
◦ Rate of falls – reduce rate of falls with injuries 1-2%
◦ Rate of decubitus ulcers – reduce by 2%
◦ Rate of quality of care complaints – reduce by 2%
44. Please download and print the following
statement, sign and date, and return it to
CarePoint. Thank you.
CarePoint MOC attestation
Questions?
David J. Sand, MD, MBA, FACS
◦ Chief Medical Officer, CarePoint Health Plans
◦ Phone: 201-432-2133 ext. 106
◦ E-mail: dsand@carepoint.org