SNP Updates November 2019

Central Health Medicare Plan’s (CHMP) Special Needs Plan (SNP) continues to address the health care needs of its members through the following:

  1. Provide health education with focus on health screening and prevention to improve the health of our SNP members in managing their various chronic health conditions. An individualized care plan (ICP) is created based on information provided by SNP members during the completion of the Health Risk Assessment (HRA), along with review of available clinical data by clinical staff. The annual HRA completion rate for 2018 was 76%, attributed to some members being unreachable. However, all members receive a care plan and the annual compliance rate for the 60 day ICP completion is 97%. And to ensure positive experience of our members, our SNP nurses, social workers and coordinators maintain a respectful interaction with all members, whether on the phone or during home visits. Our SNP members’ positive experience is evidenced by our score of 94% on our 2018 annual Member Satisfaction Survey result. We encourage our member’s health care providers to participate in our weekly interdisciplinary team meeting (ICT) to address member’s needs. To ensure effective partnership and collaboration with our providers, we continue to provide annual training in our MOC. Please go to to complete this training as required by CMS and complete the Attestation Form.

  2. In response to the arrival of the 2019-2020 flu season, CHMP conducted 4 Health Fairs to provide flu vaccine to its members at its 2 Wellness Center locations (Alhambra and City of Industry) in September and October. There were 474 Plan members who participated. In addition to the flu shots, blood pressure, weight and bone density tests were also measured. To date, an additional 140 members have received their flu vaccines during their scheduled preventive service encounter at the Wellness Centers. We continue to encourage our members to schedule an appointment for preventive services as well as follow-up with their health care providers to obtain their flu vaccine.

  3. Despite new guidelines and advances in the management of various chronic medical conditions, the goal of reducing the need for hospitalization, reduction of total medical cost and improving quality of life remains a challenge for the SNP population. The SNP team continues to coordinate care with CHMP’s inpatient case managers to address our members’ transition of care (TOC) needs. Our goal is to provide support to both the enrollee and their caregivers. There is on-going referral to our home visit team for high risk members to reinforce health education, self-care, establishing appropriate emergency plans, increasing needed adherence to treatment plan, as well as discussing consideration for palliative or hospice care in select patients. Members’ Interdisciplinary Care Plans (ICPs) are revised and updated after each TOC event. Based on Quarter 2 data of the current year, the 30 day readmission rate for MA 002 was 13%, MA 006 22%, MA009 6% and MA 014 0%. Members enrolled in MA 006 have a diagnosis of Diabetes and or cardiovascular disorders (i.e. Cardiac Arrhythmias, Coronary Artery Disease, Peripheral Vascular Disease, chronic venous thromboembolic disorder) or Congestive Heart Failure. Barriers to achieving goal include the presence of complex comorbid conditions, absence or inadequate support system, socioeconomic status, knowledge deficit, and non-compliance to medication and therapeutic lifestyle.

  4. Health maintenance and prevention of disease progression remains a priority goal for the SNP Team. With the pre-diabetes population increasing, it is imperative to prevent progression of the condition to Type 2 Diabetes, which is a major risk factor for stroke and heart disease. CHMP started the Diabetes Prevention Program in April 2018, with the 1st cohort having completed their one year commitment to the program in April of this year. The curriculum focuses on lifestyle modification. In addition to classroom instruction, an activity such as the "Walking Club" was incorporated to keep the members engaged and interested in completing the program. CHMP recently received CDC Preliminary Recognition, which is an important step toward achieving CDC Full recognition. The 2nd cohort for the program started in June 2019, in response to the increased number of members with Pre-DM as well as positive feedback received from the 1st cohort. For members who already have a diagnosis of diabetes, we have established a goal of having more than 60% of them achieve an A1C goal of < 9%. Based on the SNP Diabetic HbA1C trend for 2019, Quarter 3 data, 93%, 82%, 86%, and 50% of members enrolled in MA002, MA006, MA009, and MA 014 who have already tested have achieved an A1C of < 9%, respectively. In addition, the percentage of those who achieved an A1C of < 8% among those who have already tested is 86%, 66%, 77%, and 25% for MA 002, MA 006, MA 009, and MA 014, respectively.

  5. Congestive heart failure (CHF) is another public health problem that many SNP members share, which substantially contributes to morbidity and mortality. CHMP’s Congestive Heart Failure Quality Improvement Program (CHF QIP) targets high risk members with heart failure. There is on-going data collection to analyze the impact on hospital re-admissions, ED visits and quality of life for these members. As of Quarter 3 data, those members who consented to home visit had an 18% and 24% re-admission and ED encounter rate, respectively, compared to 24% and 26% re-admission and ED encounter rate among those who either declined or were unreachable for home visit. The in-patient case managers who conduct post hospital discharge calls as well as the GRACE team, who conduct home visits, utilize the CHF QIP tool, which addresses key points for CHF management: reinforce heart failure education, self-care, emergency plans, and needed adherence to medications & therapeutic lifestyle. The tool also allows for the assessment of comorbid conditions such as diabetes, hypertension, and hyperlipidemia.