Chronic Care Improvement Program (CCIP)

20.1.1 - Chronic Care Improvement Program (CCIP) (Rev. 117, Issued: 08-08-14, Effective: 08-08-14, Implementation: 08-08-14) A CCIP is a clinically focused initiative designed to improve the health of a specific group of enrollees with chronic conditions. Beginning CY 2012, CMS required that each MA plan conduct, over a 5-year period, a CCIP focused on reducing and/or preventing cardiovascular disease. CCIP Plan Section Description The CCIP Plan section describes all aspects of the proposed CCIP initiative, including, but not limited to: the opportunity for improvement, target goal, what specific interventions will be introduced to achieve the identified goal, members targeted for receipt of the intervention(s), and the expected results. Please note that we expect SNPs to develop interventions that are tailored to their specific target population. While an organization may choose the same basic intervention(s) for its SNP and non-SNP plans, we expect the intervention(s) and overall approach to appropriately address the unique characteristics and needs of the targeted populations. Below is a general summary of the required components of the CCIP Plan. • Basis for Selection - An overall description of the CCIP and rationale for selection that includes impact on the member, anticipated outcomes, and rationale for selection. • Program Design - Outlines the process used to identify the target population, risk stratification, and enrollment method. • Evidence-Based Medicine - Includes the clinical practice guidelines and standards of care to be employed. • Care Coordination Approach - Describes the expected collaboration and communication among a multidisciplinary team that may include providers, MAO staff and the targeted member. • Education - The method of education and the topics that will be addressed. Includes education directed to applicable providers and/or targeted members. • Outcome Measures and Interventions - Setting objectives in measurable terms; identifying the appropriate data source(s) to measure; and the methodology used to analyze the data to determine whether the initiative impacted the health status of the targeted population. • Communication Sources - Methods used to inform patients, physicians, and other providers on what is occurring in the CCIP and any changes necessary over time. MAOs with contracts that were operational in CY 2012 were required to submit the Plan Section of the CCIP for the first time through HPMS in 2012. In subsequent years, newly operating MAO contracts and SNPs must submit the Plan section of the PDSA during the CMS-determined submission window in the fall of their first year of operation; the first Annual Update for those plans will be submitted the following year. CCIP Annual Update Section The CCIP Annual Update is due during the CMS-determined submission window in the fall of the first year of implementation following approval of the CCIP Plan Section and annually thereafter, until program completion. The Annual Update should include the results or findings to date, based on the intervention(s); any barriers encountered during the update period; risk mitigation activities implemented to address barriers encountered; impact on the established goal or benchmark; and, next steps for the project. Below is a general summary of the components of the CCIP Annual Update. • Educational components - Includes the actual method(s) of education and the topics that were covered. The education may be patient and/or provider focused. • Intervention(s) - Specific actions/approaches implemented to achieve the stated goal. • A description of barriers encountered, if applicable, and the specific actions taken to mitigate those barriers. • Discussion of findings and analysis of results to date in relation to the established goal, benchmark, timeframe, total population, numerator, denominator, results and other data results. Identification of next steps based on internal evaluation and ongoing assessment of the CCIP, whether or not the goals were met, and any revisions to the intervention(s), methodology, goal, or other aspects of the initiative. • Best Practices - Any identified approaches that are proven to be reliable and appear to contribute to the success of the CCIP. • Lessons Learned - Description of pertinent knowledge gained through the CCIP experience.