Special Needs Plans - Preferred Care Partners Supplement, 2018 UnitedHealthcare Administrative Guide

Special Needs Plans (SNP) Model of Care (MOC)

The MOC is a framework for providing health care and health care plans designed by theory, evidence-based protocols, and accepted standards. The MOC contains specific elements that delineate implementation, analysis, and improvement of care.

These elements include description of SNP population (including health conditions), Care Coordination, ProviderNetwork and Quality Measurement and Performance Improvement.

SNP MOC Structure and Process

The structure and processes of the SNP MOC program is based on six structure and process measures to evaluate the structure, processes, and performance of SNPs. Through these measures, SNPs must demonstrate they are providing quality health care for our members.

These measures are:

  • Complex case management;
  • Improving member satisfaction;
  • Clinical quality improvements;
  • Care transitions;
  • I-SNP relationships with facility; and
  • Coordination of Medicare and Medicaid coverage.

We have a Stars Improvement Department that has a direct focus on quality performance measures. We work closely with UnitedHealthcare to improve our performance. Many of these performance measures involve you and can be positively affected by the relationship between Preferred Care Partners and its network care providers.

We strive for improved lines of communication and exchange of helpful tools and looks forward to receiving your feedback.

Risk Management

Risk management addresses liability, both proactively and reactively. Proactive is avoiding or preventing risk. Reactive is minimizing loss or damage after an adverse or bad event.

Risk management in health care considers patient safety, quality assurance, and patients’ rights. The potential for risk is present in all aspects of health care, including medical mistakes, electronic record-keeping, care provider organizations, and facility management.

An adverse event is defined as an event over which health care personnel could exercise control rather than as a result of the member’s condition. Identifying something as an adverse event does not imply “error,” “negligence” or poor quality care. It indicates that an undesirable clinical outcome resulted from some aspect of diagnosis or therapy, not an underlying disease process. Adverse events interfere with a care provider’s delivery of medical care and may result in litigation.

Agency for Healthcare Administration

The Florida Agency for Healthcare Administration (AHCA), as directed under F.S. 641 Parts I, II, III and other applicablestate laws, provides oversight and monitoring of health plans operating in the State of Florida as an HMO and their compliance to applicable regulations.

This includes implementation of a Risk Management Program (RMP). The program helps identify, investigate, analyze and evaluate actual or potential risk exposures by a state licensed risk manager. The RMP also corrects, reduces and eliminates identifiable risks through instruction and training to staff and care providers.

Examples of adverse and serious incidents as defined by AHCA include:

  • Death of a patient;
  • Severe brain or spinal damage to a patient;
  • Performance of a surgical procedure on the wrong patient;
  • Performance of a wrong site surgical procedure; or
  • Performance of a wrong surgical procedure.

For more information, go to the AHCA website at ahca.myflorida.com.