Clinical Practice Guidelines
SECUR Health Plan has developed a guide for healthcare providers to assist in delivering high-quality, evidence-based care to our members. The goal is to ensure consistent and coordinated care across the care continuum, focusing on improving health outcomes, enhancing member satisfaction, and managing healthcare costs effectively.
Overview of I-SNP
An I-SNP (Institutional Special Needs Plan) is a type of Medicare Advantage plan designed specifically for individuals living in institutional settings, such as nursing homes or other long-term care facilities. The IE-SNP is a variation of the I-SNP, but it generally serves people who are eligible for Medicare and Medicaid and have specific needs related to residing in an institution but may reside in the community. SECUR offers both types of plans, SECUR Advantage (I-SNP) and SECUR Enhanced (IE-SNP). These plans are tailored to meet the healthcare needs of frail, elderly individuals with chronic conditions, cognitive impairments (such as dementia), or other special health needs that require coordinated, comprehensive care. The model for both plan types is centered around an interdisciplinary care team (ICT) approach, including physicians, nurses, social workers, and other healthcare professionals.
Care Coordination and Communication
Objective: Ensure that all members of the healthcare team collaborate and communicate effectively to provide seamless and continuous care for SECUR Health Plan members.
- Physicians and Nurses should actively participate in interdisciplinary care team meetings.
- Communication: Use electronic health records to communicate treatment plans, medication changes, and care updates.
- Care Plans: Develop individualized care plans that are updated regularly and communicated to all members of the ICT. Ensure that care plans reflect the member’s preferences and goals.
- Transitions of Care: Ensure smooth transitions between care settings (e.g., from hospital to nursing home) by maintaining clear, comprehensive documentation and communication regarding ongoing treatment and management needs.
Comprehensive Assessment
Objective: Conduct a thorough, member-centered assessment at regular intervals to identify medical, social, and psychological needs.
- Initial Assessment: Within 90 days of enrollment, perform a comprehensive assessment that includes:
- Medical history, including co-morbidities.
- Functional status (e.g., activities of daily living).
- Cognitive status (e.g., screening for dementia or delirium).
- Mental health and psychosocial needs.
- Medications and potential interactions.
- Routine Reassessments: Perform reassessments based on the member’s assessed risk score and if there are changes in the member's condition.
- Health Risk Assessment (HRA): Regularly assess risk factors, including fall risk, malnutrition, and pressure ulcers.
- Coverage Determinations: For SECUR Health Plan members, National Coverage Determinations (NCD) and Local Coverage Determinations (LCD) will be applied to requests when applicable. SECUR Health Plan Coverage Determination Guidelines (CDG) will be utilized in the absence of an appropriate NCD and/or LCD. Click here for more details.
Chronic Disease Management
Objective: Manage chronic diseases to reduce complications, hospitalizations, and improve the quality of life for SECUR Health Plan members.
- Individualized Care Plans: Tailor care plans to address chronic conditions (e.g., diabetes, hypertension, heart failure) and monitor outcomes.
- Medications: Regularly review medication lists for potential interactions, appropriateness, and adherence.
- Case Management: Case management helps individuals with chronic diseases by coordinating personalized care, ensuring access to necessary resources, and providing ongoing support to improve health outcomes and quality of life.
Acute and Episodic Care
Objective: Provide timely, effective interventions for acute medical conditions and episodic care needs to prevent complications.
- Acute Illness Protocol: Follow evidence-based protocols for managing acute conditions like infections, dehydration, or exacerbations of chronic illnesses.
- Hospitalization Prevention: Focus on preventing unnecessary hospitalizations by managing acute conditions within the facility when appropriate. Utilize telemedicine and urgent care services as alternatives to emergency department visits.
- Post-acute Care: Coordinate follow-up care after hospital discharge, including medication reconciliation, physical therapy, and ongoing medical management.
Palliative and End-of-Life Care
Objective: Provide compassionate, member-centered care for individuals with life-limiting illnesses, ensuring comfort and quality of life.
- Palliative Care: Offer early palliative care consultations for members with serious, progressive illnesses, addressing pain and symptom management.
- Advance Directives: Ensure that all members have advance care planning discussions and documented preferences for care at the end of life, including the use of Do Not Resuscitate (DNR) orders and POLST (Physician Orders for Life-Sustaining Treatment).
- Hospice Care: Facilitate access to hospice services when appropriate, ensuring comfort and quality of life during the final stages of life.
Infection Prevention and Control
Objective: Prevent and manage infections, particularly in long-term care settings where residents are at high risk.
- Hand Hygiene: Ensure strict adherence to hand hygiene protocols for all healthcare providers, members, and visitors.
- Vaccination: Ensure all members are up to date on vaccinations, including influenza, pneumococcal, and COVID-19.
- Surveillance: Monitor for signs and symptoms of infections (e.g., urinary tract infections, pneumonia) and implement appropriate isolation protocols when necessary.
- Antibiotic Stewardship: Promote appropriate use of antibiotics to reduce resistance and adverse outcomes from overuse.
Behavioral Health and Mental Health
Objective: Address the mental health needs of SECUR Health Plan members, including depression, anxiety, and dementia-related behaviors.
- Routine Screening: Screen for depression, anxiety, and cognitive impairments (e.g., using the PHQ-9 or Geriatric Depression Scale).
- Care for Dementia: Provide individualized care strategies for members with Alzheimer’s disease and related dementias, including non-pharmacologic approaches and appropriate medication management.
- Psychiatric Consultations: Facilitate access to psychiatry or psychotherapy services when indicated.
Member and Family Education
Objective: Empower members and their families to manage health conditions and understand treatment options.
- Education Materials: Provide culturally appropriate educational materials to members and families on managing chronic conditions, medications, and activities of daily living.
- Caregiver Support: Offer caregiver education and support, addressing common challenges faced by those caring for frail older adults.
- Advance Care Planning: Educate members and families about advance directives, healthcare proxy, and other planning documents to ensure care preferences are known and respected.
Quality Improvement and Data Collection
Objective: Continuously monitor and improve care quality based on performance metrics and member outcomes.
- Data-Driven Decisions: Utilize SECUR Health Plan data to track key quality indicators such as hospital readmission rates, medication adherence, and care gaps.
- Feedback Loops: Regularly review member outcomes and process measures as part of a quality improvement program. Engage in ongoing education and process improvements to ensure high standards of care.
- Member Satisfaction: Collect member and family feedback regarding satisfaction with care and use this information to refine care delivery.
Ethical and Legal Considerations
Objective: Ensure that care provided is ethical, legal, and compliant with relevant regulations and standards.
- Confidentiality: Maintain member privacy and confidentiality in accordance with HIPAA and other relevant laws.
- Ethical Dilemmas: Address ethical issues (e.g., end-of-life care decisions, resource allocation) by consulting with ethics committees or social workers as appropriate.
- Regulatory Compliance: Adhere to all relevant state, federal, and Medicare regulations regarding the care of institutionalized individuals, ensuring compliance with I-SNP/IE-SNP-specific requirements.
Additional Resources
Need assistance? Have questions?
Contact our Provider Relations Team at [email protected] or call 1.833.76SECUR (1.833.767.3287). TTY is 711.
4200 W. Cypress Street, Suite 690, Tampa, FL 33607
Phone: 813.357.5300 | Toll-Free: 1.833.767.3287 (TTY 711)
[email protected]
