MOC 2 Scoring Guidelines

MOC 2: Care Coordination

Care coordination helps ensure that SNP beneficiaries’ health care needs, preferences for health services and information sharing across health care staff and facilities are met over time. Care coordination maximizes the use of effective, efficient, safe, high-quality patient services (including services furnished outside the SNP’s provider network) that ultimately lead to improved health care outcomes.

The following MOC elements are essential components to consider in the development of a comprehensive care coordination program; no element must be interpreted as being of greater importance than any other. Taken together, all five elements must address the SNP’s care coordination activities comprehensively.

Element A: SNP Staff Structure

The organization’s MOC description of its target SNP population must:

  1. Describe the administrative staff’s roles and responsibilities, including oversight functions.
  2. Describe the clinical staff’s roles and responsibilities, including oversight functions.
  3. Describe how staff responsibilities coordinate with the job title.
  4. Describe contingency plans used to address ongoing continuity of critical staff functions.
  5. Describe how the organization conducts initial and annual MOC training for its employed and contracted staff.
  6. Describe how the organization documents and maintains training records as evidence that employees and contracted staff completed MOC training.
  7. Describe actions the organization takes if staff do not complete the required MOC training.

Scoring

100%: The organization meets all 6-7 factors
80%: The organization meets 4-5 factors
50%: The organization meets 3 factors
20%: The organization meets 1-2 factors
0%: The organization meets no factors

Explanation

Factor 1: Administrative staff roles and responsibilities

The organization’s MOC defines staff roles and responsibilities across all health plan functions for personnel that directly or indirectly affect the care coordination of SNP beneficiaries.

The organization’s MOC must identify and describe the specific employed and contracted staff responsible for performing administrative functions, including:

  • Enrollment and eligibility verification.
  • Claims processing.
  • Administrative oversight.

Factor 2: Clinical staff roles and responsibilities

The organization must identify and describe the employed and contracted staff that perform clinical functions, including:

  • Direct beneficiary care and education on self-management techniques.
  • Care coordination.
  • Pharmacy consultation.
  • Behavioral health counseling.
  • Clinical oversight.

Staff oversight responsibilities must include any license and competency verification that relates to the specific population being served by the organization (e.g., geriatric training for I-SNP providers or special training for physicians and other clinical staff for a C-SNP services beneficiaries with HIV/AIDs; data analyses for utilization of appropriate and timely health care services; utilization review; and provider oversight to ensure use of appropriate clinical practice guidelines and integration of care transition protocols.

Factor 3: Coordination of responsibilities and job title

To show how staff responsibilities identified in the MOC are coordinated with job title, the organization must provide a copy of its organization chart and, if applicable, a description of instances when a change to staff title/position or level of accountability is required to accommodate operational changes in the SNP.

Factor 4: Contingency plan

The organization must have a contingency plan (or plans) in place to avoid a disruption in care and services when existing staff can no longer perform their roles and meet their responsibilities. The organization’s MOC must identify and describe contingency plans to ensure ongoing continuity of staff functions.

Factors 5 & 6: Initial and annual MOC training; maintaining training records

The organization must conduct initial and annual MOC training for its employed and contracted staff. The MOC must describe the training strategies and content, as well as the methodology the organization uses to document and maintain training records as evidence that staff have completed MOC training. Contracted staff do not include physicians or other providers that the organization contracts with as part of the provider network.

The description must include types of trainings and specific examples of slides or training materials. If the training plan is not currently operational, the organization’s MOC must provide a description of the plan’s contents.

Factor 7: Actions if training is not completed

The organization’s MOC must explain challenges associated with employed and contracted staff completing training and must describe actions the organization will take when the required MOC training has not been completed or has been found to be deficient.

Element B: Health Risk Assessment Tool (HRAT)

The organization’s MOC includes a clear and detailed description of the policies and procedures for completing the HRAT that addresses:

  1. How the organization uses the HRAT to develop and update the Individualized Care Plan (ICP) for each beneficiary (Element 2C).
  2. How the organization disseminates the HRAT information to the Interdisciplinary Care Team (ICT) and how the ICT uses that information (Element 2D).
  3. How the organization conducts the initial HRAT and annual reassessment for each beneficiary.
  4. The detailed plan and rationale for reviewing, analyzing and stratifying (if applicable), the HRA results.

Scoring

100%: The organization meets all 4 factors
80%: The organization meets 3 factors
50%: The organization meets 2 factors
20%: The organization meets 1 factors
0%: The organization meets no factors

Explanation

The content of and methods used to conduct the HRAT have a direct effect on the development of the ICP and ongoing coordination of ICT activities. The HRAT must assess the medical, functional, cognitive, psychosocial and mental health needs of each SNP beneficiary.

Factors 1 & 2: Use and dissemination of HRAT information

The organization must include a description of how the HRAT is used to develop and update, in a timely manner, the ICP for each beneficiary and how the HRAT information is disseminated to and used by the ICT.

Factor 3: Initial HRA and annual reassessment

The organization must complete the HRAT for each beneficiary, for initial assessment, and must complete an HRAT annually thereafter. At minimum, the organization must conduct initial assessment within 90 days before or after a beneficiary’s effective enrollment date and must conduct annual reassessment within one year of the initial assessment.

The description must include the methodology used to coordinate the initial and annual HRAT for each beneficiary (e.g., mailed questionnaire, in-person assessment, phone interview) and the timing of the assessments. There must be a provision to reassess beneficiaries, if warranted by a health status change or care transition (e.g., hospitalization, change in medication, multiple falls). The organization must describe its process for attempting to contact beneficiaries and have them complete the HRAT, including provisions for beneficiaries that cannot or do not want to be contacted or complete the HRAT.

Factor 4: Plan and rationale

The organization’s MOC must describe its plan and explain its rationale for reviewing, analyzing and stratifying HRAT results. It must include the mechanisms for communicating information to the ICT, provider network, beneficiaries and/or their caregivers and other SNP personnel who may be involved with overseeing a beneficiary’s plan of care. If the organization uses stratified results, the MOC must explain how the SNP uses the results to improve the care coordination process.

Element C: Individualized Care Plan (ICP)

The description of the organization’s ICP must include:

  1. The essential components of the ICP.
  2. The process to develop the ICP, including how often the ICP is modified as beneficiaries’ health care needs change.
  3. The personnel responsible for development of the ICP, including how beneficiaries and/or caregivers are involved.
  4. How the ICP is documented, updated and where it is maintained.
  5. How updates and modifications to the ICP are communicated to the beneficiary and other stakeholders.

Scoring

100%: The organization meets all 5 factors
80%: The organization meets 4 factors
50%: The organization meets 2-3 factors
20%: The organization meets 1 factors
0%: The organization meets no factors

Explanation

Factor 1: ICP essential components

The organization must develop an ICP for each beneficiary, to deliver appropriate care to the beneficiary. The organization’s ICP must include, but is not limited to:

  • The beneficiary’s self-management goals and objectives.
  • The beneficiary’s personal healthcare preferences.
  • A description of services specifically tailored to the beneficiary’s needs.
  • Identification of goals (met or not met).
    • If the beneficiary’s goals are not met, the organization’s MOC must describe the process for reassessing the current ICP and determining the appropriate alternative actions.

Factors 2 & 3: ICP development process and personnel

The organization’s MOC must describe the process for developing the ICP and must detail the personnel responsible for developing the ICP. The description of responsible staff must include roles and functions, professional requirements and credentials necessary to perform these tasks, as well as how the beneficiary or their caregiver/ representative is involved in the ICP development. The MOC must also include a description of how the organization determines how often to review and modify, as appropriate, the ICP as the beneficiary’s health care needs change.

Factor 4: ICP documentation and maintenance

The organization’s MOC must describe how the ICP is documented and updated and where the documentation is maintained so it is accessible to the ICT, provider network and beneficiaries and/or their caregivers.

Factor 5: Updates and modifications

The organization’s MOC must describe how the organization communicates ICP updates and modifications to beneficiaries and/or their caregivers, the ICT, applicable network providers, other SNP personnel and other stakeholders, as necessary.

Element D: Interdisciplinary Care Team (ICT)

The organization’s MOC must describe the critical components of the ICT, including:

  1. How the organization determines the composition of ICT membership.
  2. How the roles and responsibilities of the ICT members (including beneficiaries and/or caregivers) contribute to the development and implementation of an effective interdisciplinary care process.
  3. How ICT members contribute to improving the health status of SNP beneficiaries.
  4. How the SNP’s communication plan to exchange beneficiary information occurs regularly within the ICT, including evidence of ongoing information exchange.

Scoring

100%: The organization meets all 4 factors
80%: The organization meets 3 factors
50%: The organization meets 2 factors
20%: The organization meets 1 factors
0%: The organization meets no factors

Explanation

Factor 1: ICT membership

The organization’s MOC must describe the composition of the ICT, including how the SNP determines ICT membership and the roles and responsibilities of each member. The description must specify how the expertise and capabilities of the ICT members align with the identified clinical and social needs of the SNP beneficiaries.

The organization must:

  • Explain how the SNP facilitates the participation of beneficiaries and their caregivers as members of the ICT.
  • Describe how the beneficiary’s HRAT and ICP are used to determine the composition of the ICT; including where additional team members are needed to meet the unique needs of a beneficiary.
  • Explain how the ICT uses health care outcomes to evaluate processes established to manage changes or adjustments to the beneficiary’s health care needs on a continuous basis.

Factors 2 & 3: ICT member roles and responsibilities

The organization’s MOC must describe how it uses clinical managers, case managers and others who play critical roles in providing an effective interdisciplinary care process; and how beneficiaries and/or their caregivers are included in the process, are provided with needed resources and how the organization facilitates access for beneficiaries to ICT team members.

Factor 4: Communication plan

The MOC must describe the SNP’s communication plan for promoting regular exchange of beneficiary information within the ICT. The MOC must show:

  • Clear evidence of an established communication plan that is overseen by SNP personnel who are knowledgeable and connected to multiple facets of the SNP MOC.
  • How the SNP maintains effective and ongoing communication among SNP personnel, the ICT, beneficiaries and/or their caregivers, community organizations and other stakeholders.
  • The types of evidence used to verify that communications have taken place (e.g., written ICT meeting minutes, documentation in the ICP).
  • How communication is conducted with beneficiaries who have hearing impairments, language barriers and cognitive deficiencies.

Element E: Care Transition Protocols

The organization’s MOC describes the following care transition protocols:

  1. How the organization uses care transition protocols to maintain continuity of care for SNP beneficiaries.
  2. The personnel responsible for coordinating the care transition process.
  3. How the organization transfers elements of the beneficiary’s ICP between health care settings when the beneficiary experiences an applicable transition in care.
  4. How beneficiaries have access to personal health information to facilitate communication with providers in other healthcare settings.
  5. How beneficiaries and/or caregivers will be educated about the beneficiary’s health status to foster appropriate self-management activities.
  6. How the beneficiaries and/or caregivers are informed about the point of contact throughout the transition process.

Scoring

100%: The organization meets all 6 factors
80%: The organization meets 4-5 factors
50%: The organization meets 3 factors
20%: The organization meets 1-2 factors
0%: The organization meets no factors

Explanation

Definitions
Health care setting: The provider from whom or setting where a member receives health care and health-related services. In any setting, a designated practitioner has ongoing responsibility for a member’s medical care.

  • Settings include home, home health care, acute care, skilled nursing facility, custodial nursing facility, rehabilitation facility and outpatient/ambulatory care/ surgery centers.

Transition: Movement of a member from one care setting to another as the member’s health status changes.

  • For example, moving from home to a hospital as the result of an exacerbation of a chronic condition or moving from the hospital to a rehabilitation facility after surgery.

Transition process: The period from identification of a member who is at risk for a care transition through completion of a transition.

  • This process includes planning and preparation for transitions and the follow-up care after transitions are completed.

Factor 1: Continuity of care

Older or disabled adults moving between different health care settings are particularly vulnerable to receiving fragmented and unsafe care when transitions are poorly coordinated; thus, an organization must work actively to coordinate transitions. The organization must specify the process and rationale for connecting beneficiaries with the appropriate providers.

Factor 2: Care transition personnel

The organization must identify and describe the personnel (e.g., case manager) responsible for coordinating the care transition process and for ensuring that follow-up services and appointments are scheduled and performed.

Factor 3: Applicable transitions

The organization must ensure that elements of the beneficiary’s ICP are transferred between health care settings when the beneficiary experiences a transition in care. The MOC must describe the steps that take place before, during and after a transition in care has occurred for this process.

Factor 4: Beneficiary personnel health information

Beneficiaries and/or their caregivers need access to beneficiaries’ personal health information in order to communicate about care with healthcare providers in other health care settings and/or health specialists outside their primary care network. The organization must describe the process for ensuring that SNP beneficiaries and/or their caregivers have access to and can adequately use personal health information to coordinate care for the beneficiary.

Factor 5: Self-management activities

The MOC must describe how beneficiaries and/or their caregivers will be educated about their condition, how they will demonstrate understanding of changes in their condition (improvement, stable or worsening), and use of appropriate self-management activities. For example, they should be educated about signs and symptoms signaling a change in their condition and how to respond to such changes. Self-management activities can include regular assessment of progress, goal setting and problem solving support to reduce crises and improve health outcomes.

Factor 6: Notification of point of contact

The organization must describe the process it uses to notify beneficiaries and/or their caregivers of the personnel responsible for supporting them through transitions between any two care settings.