The 2013 Dual Eligible SNPs Program Goals are:
* Increased access to medical, mental health and social services demonstrated by 3% increase in referrals to these services (PCP, Specialist provider, MHSA/PsychCare, MTM/Outcomes)
* Promote healthy lifestyle changes through improved access to preventive health services as demonstrated by 3% improvement in the following Health Effectiveness Data and Information Set (HEDIS) indicators and 100% of members receiving education related to self directed care:
Osteoporosis Management in Older Women
* Improve member perception of independence and self-care management skills by 3%
* Reduce dependence on Emergency Department (ED) treatment as evidenced by a 1.5% decrease in ED visits from previous year
* Reduce inpatient facility admission (IP) rate by 1.5% from previous year
* Reduce readmission rate by 1.5% from previous year
* Increase HRA completion rate within 30 days by 1% from previous year
* Increase specialist provider training by 1% from previous year
* Improve coordination of care through:
An identified point of contact, the Care Manager, in 100% of managed members
Individualized Care Plans created for 100% of SNP enrolled members
* Improve transitions of care through:
Improving timeliness of Post Discharge Support contact by 5%
Improve process to communicate ICT reviews with PCPs via telephonic and written communication methods
* Conduct ICT reviews on 80% of managed SNP members annually
* Improve member satisfaction with health status and care management services by 3%
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