CMS Pub. 100-16, ch. 5, § 20.1.1

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.