Central Health Medicare Plan (CHMP) continues to offer the Special Needs Plan (SNP) in order to improve the quality of care for our SNP members. The following are CHMP’s SNP Program updates:
The creation of an individualized care plan (ICP) is 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. This is followed by discussion of the ICP with all SNP Members. As of 3rd Quarter 2018, our HRA completion rate has increased to 86% and the timely discussion of the care plan to 97%. By providing health education, CHMP’s SNP team aims to improve the health of our SNP members in managing their various chronic health conditions.
There is on-going coordination between CHMP’s inpatient case managers and SNP team to address our members’ transition of care (TOC) needs. Reduction in 30day readmission rate as well as bed days continues to be a challenge with members who have complex comorbid conditions. In 2017, CHMP’s readmission rate was 15% for both 002 & 006 and 17% for 009 members. To improve the quality of life of our SNP members, the GRACE Team (Nurse Practitioner/Physician Assistant and Social Worker) continue to conduct home visits and follow-up calls with our high risk members. Our goal is to promote knowledge and skills regarding prescribed treatment regimens, with an emphasis on therapeutic lifestyle modifications, and to support the enrollee and their caregivers in maintaining optimum health status through improved self-care. This is especially important for our members who are enrolled in the Congestive Heart Failure Quality Improvement Project (CHF QIP).
Diabetes continues to be one of the most challenging chronic health conditions that our SNP members face. Based on our 2018 year to date data, we have exceeded our goal of more than 60% of our SNP members achieving an HbA1c score of < 9% (002 = 95%, 006 = 83%, 009 = 91%). In addition, we are addressing the needs of our growing number of members with Prediabetes. We have started the Diabetes Prevention Program (DPP) in March 2018, which focuses on education related to lifestyle changes to prevent members from progressing to Type 2 Diabetes as well as reduce their risk for heart disease and stroke. The program requires a one year commitment to attending the classes and our first cohort is half way through the program. The need, coupled by the positive feedback provided by the participants, has paved the way to coordinating the start of a 2nd cohort.
With the start of the flu season, and in keeping with our goal of health promotion and disease prevention, CHMP conducted 4 Health Fair events in September and October at both the Alhambra Wellness Center and Industry Wellness Center. A total of 383 CHMP members participated. In addition to the administration of the flu vaccine, CHMP staff conducted bone density testing to screen for osteoporosis and quantaflo testing to screen for peripheral artery disease. Members had an opportunity to get answers to their health related questions from the nurse practitioners and physician assistants on site. There is ongoing flu vaccination at both these Wellness Center sites for the remainder of the flu season and 101 additional members have received theirs during their scheduled visit. CHMP also participated in a Marketing event in October and provided 169 flu vaccines to non-CHMP members.
Establishing rapport during ICP discussion by phone or during home visit is a critical part in providing effective health education. Our SNP members’ positive experience is evidenced by our consistent score of > 90% on our Member Satisfaction Survey results.
To ensure effective partnership and collaboration with our providers, we continue to provide annual training in our MOC.
Providers may access this training at https://www.centralhealthplan.com/cpa/Home/SNP to complete this training, as required by CMS, and complete the Attestation Form.