Arizona Long Term Care System (ALTCS) Performance Measure INITIATION OF HOME AND COMMUNITY BASED SERVICES August 2004 Anthony D. Rodgers Director Arizona Health Care Cost Containment System (AHCCCS) Arizona Long Term Care System (ALTCS) Performance Indicator: INITIATION OF HOME AND COMMUNITY BASED SERVICES For the Measurement Periods October 1, 2001, through September 30, 2002, and October 1, 2002, through September 30, 2003 Overview Home and community-based services (HCBS) have become a growing part of states’ Medicaid long-term care programs, providing an alternative to institutional care, such as nursing homes, for the elderly and physically disabled. Nationwide, HCBS expenditures grew tenfold in just over a decade: from approximately $1.6 billion in 1991 to $16.4 billion in 2002. At the same time, the proportion of Medicaid dollars spent on institutional care declined.1,2 As of September 30, 2003, more than 20,000 elderly and physically disabled (E/PD) members were enrolled in ALTCS. More than half (58 percent) resided in home and community-based settings. By providing a variety of alternative settings with differing levels of care, ALTCS members are able to delay institutionalization or, in some cases, transfer from nursing home care into the HCBS program. In addition to the savings experienced by using HCBS, this approach provides members with a degree of independence and control not available in an institutional setting. Fueling this growth are consumers’ preferences to reside in their own homes rather than nursing homes, and changes in federal and state policy that support lesscostly home and community-based services.3 According to a 2003 report from the U.S. General Accounting Office, several states may lack adequate quality assurance mechanisms for their HCBS programs.1 However, Arizona has established a number of mechanisms to ensure that people are placed in programs that provide the proper level of care and that services are monitored. These include case management service reviews and monitoring timeliness of service initiation. The Arizona Health Care Cost Containment System (AHCCCS) has provided HCBS to long-term care beneficiaries through a waiver from the Centers for Medicare and Medicaid Services (CMS) since 1989. Through its Arizona Long Term Care System (ALTCS), AHCCCS provides comprehensive coverage for HCBS members residing in their own homes or in approved alternative residential settings, such as assisted living facilities or group homes. Covered services include care such as home health nursing, attendant care, and physical or speech therapy. Once eligibility for ALTCS is determined based on financial and medical criteria, E/PD members enroll with a contracted health plan (Contractor), depending on where they live. Each member is assigned a case manager, who coordinates care with the member’s primary care provider (PCP), 1 • addresses any problems with service delivery and modifies the member’s care plan based on changes in health status. Case managers visit new members and, in conjunction with members and/or their authorized representatives, assess their needs to determine the most appropriate placement. Services must be initiated within timelines to meet the member’s medical needs, but no later than 30 calendar days from their enrollment (except ventilator-dependent members, for whom services must be initiated no later than 10 working days after enrollment). • What is the number and percentage (overall, by urban and rural counties, and by individual Contractor) of sample members to whom a home and community-based service was provided within 30 days of enrollment? For those members who did not receive services within 30 days of enrollment, what were the reasons? The study covered two measurement periods: October 1, 2001, through September 30, 2002, and October 1, 2002, through September 30, 2003. The sample frame consisted of E/PD members who: • were enrolled for 30 days or more with an ALTCS Contractor during one of the measurement periods, and • were newly placed in the HCBS program. As part of its quality assessment and performance improvement program for ALTCS services, AHCCCS measures the percentage of newly placed HCBS members who received selected services within 30 days of enrollment. Examples of these services include adult day health care, attendant care, home-delivered meals, home health nursing and homemaker assistance (a complete list of services and service codes included in this study is found in Appendix A, Methodology and Technical Specifications). This study did not include members who were enrolled in the Ventilator Dependent program or with tribal Contractors. A representative random sample was selected for each Contractor. Data was first collected from AHCCCS encounter data (records of claims paid by Contractors). If services within 30 days of enrollment were not found in AHCCCS encounter data, Contractors were asked to provide service delivery information from medical or case management records or their claims data. It should be noted that this Performance Indicator does not include all covered home and community-based services. For example, emergency-alert and homemodification services are not included because they are typically provided in conjunction with nursing, personal care or supportive services. The intent of this indicator is to measure the health care services that primarily allow members at risk of institutionalization to remain in their homes or community-based settings. In analyzing the first study question (initiation of services within 30 days), AHCCCS excluded members who: • refused services, • were hospitalized during the first 30 days after enrollment, • were receiving hospice services during the first 30 days after enrollment, • were residing in an assisted living facility and thus receiving services, or Methodology Similar to previous HCBS studies, the methodology for this measurement is based on two study questions: 2 • facilities, or case managers were unable to contact them to set up initial visits after several attempts (Table 1). could not be contacted after several attempts by the Contractor. To validate additional information collected by Contractors, AHCCCS required documentation of services provided or reasons why a member did not receive services (for example, the member refused services while waiting for a family member to become trained to provide attendant care or was hospitalized during all or part of the first 30 days of enrollment). Documentation provided by Contractors included copies of the pertinent sections of case management records, medical/service records from providers, or verification of claims paid by Contractors for qualifying services. Among the remaining 521 people, 435 received services within 30 days of enrollment. The overall rate of initiation of services was 83.5 percent (Table 2). Initiation of Services Within 30 Days 10/01-9/02 Received Services The results of this study cannot be compared to previous studies of initiation of home and community-based services by AHCCCS, because of changes in methodology (deviations from previous methodology are included in Appendix A). Did Not Receive Services Rates by Contractor ranged from 69.7 percent to 98.0 percent. The rate of initiation of services in rural counties was 87.6 percent, compared with 81.0 percent in urban counties. Indicator Goals AHCCCS has established a Minimum Performance Standard that Contractors achieve a rate of at least 74 percent for this indicator. AHCCCS also has established a benchmark, or long-range goal, that Contractors achieve a rate of at least 87 percent for this measure. Second measurement period. For the period October 1, 2002, through September 30, 2003, 686 HCBS members were selected for the study. Results First measurement period. For the period October 1, 2001, through September 30, 2002, 787 HCBS members were selected for the study. Of those, 227 people were excluded from the analysis of initiation of services for the reasons previously identified (Table 1). Of those, 266 people were excluded from the analysis of initiation of services because they refused services, were hospitalized, were receiving hospice services, were residing in assisted living Among the remaining 459 people, 384 received services within 30 days of enrollment. The overall rate of initiation of services for this measurement period was 83.7 percent (Table 2). 3 n and five Contractors exceeded the standard for the second measurement period. Four Contractors exceeded the Minimum Performance Standard in both periods. Initiation of Services Within 30 Days 10/02-9/03 Received Services Initiation of Services within 30 Days: Rural vs. Urban Areas 100% Did Not Receive Services 80% 60% 40% Rates by Contractor ranged from 68.4 percent to 97.8 percent. The rate of initiation of services in rural counties was 87.9 percent, compared with 81.3 percent in urban counties. 20% 0% 10/01-9/02 Rural Analysis The rate of initiation of services within 30 days remained virtually unchanged from the first measurement period to the second measurement period. 10/02-9/03 Urban Conclusions and Recommendations A large majority of ALTCS members who are newly placed in the HCBS program are receiving services within 30 days of enrollment. These services are designed to enable long-term care recipients to remain in their homes or the community. Pearson’s Chi-square analysis revealed that, for the first measurement period, members living in rural counties were more likely to have received one of the services measured within 30 days of enrollment than members living in urban areas (p = .050). This is somewhat surprising, given the fact that capacity for some health care services may be more limited in rural areas, compared with urban communities. However, other AHCCCS studies have shown similar results. There was no significant difference in the second measurement period. In addition, most ALTCS E/PD Contractors are meeting the AHCCCS Minimum Performance Standard for initiation of home and community-based services. The declines in rates of two Contractors may be caused by data issues that affected the most recent measurement period. Both Contractors, Evercare Select and Maricopa Long Term Care, were not able to provide documentation verifying initiation of services to the same extent that they had for the first measurement period. In particular, Maricopa LTC has experienced severe problems with its Six of seven Contractors exceeded the AHCCCS Minimum Performance Standard in the first measurement period, 4 agency to provide housekeeping, can be accomplished. claims system that may have affected the ability of both AHCCCS and the Contractor to collect and document service delivery information. While much has been written about the financial aspects of HCBS programs nationally, there is little published about quality improvement initiatives in this area. However, lessons learned from disease management programs can offer insights into improving the timeliness of services provided in home and communitybased settings, which could improve the health status of these members. These lessons include: 4 • Build ongoing relationships with PCPs and other providers. This enables case management staff to coordinate care and to facilitate communication. Evidence suggests that programs failing to engage the client’s physician may have limited ability to address the medical aspects of care coordination. • Build ongoing relationships with the client and family members. The foundation for this relationship often is laid during the initial assessment. • Monitor to make certain that planned interventions get done. This could entail checking back with ALTCS members before the 30th day after enrollment, to ensure they received the services ordered. Since much of the data for this indicator is collected from case management records when claims or encounters for services are not available, Contractors should ensure that case managers thoroughly and consistently document when home and community-based services are initiated for new members. Case managers also should carefully document when a member or authorized representative refuses services. This may happen when an enrollee is waiting for a family member to become trained to provide attendant care and does not want another person coming in to his or her home to provide services in the meantime. Services may be more difficult to put in place when members have limited English proficiency. During this study, it was noted that, in some cases, Contractors took longer to initiate services because they could not find an agency with staff who spoke a particular language. Contractors should assess their HCBS provider networks to ensure they have adequate staff to provide services to members in these situations. Many ALTCS Contractors or individual case managers already practice these strategies. The challenge in improving HCBS delivery is to ensure these methods are consistently utilized. AHCCCS will facilitate sharing of “best practices” in initiating care. For example, one ALTCS Contractor has set a timeframe for scheduling the initial face-to-face assessment with new members that is shorter than the maximum of 12 days set by AHCCCS. The sooner an assessment of service needs occurs after enrollment –— for example, within seven days — the more likely the processes necessary to begin care, such as prior authorization or ordering and setting up services from an Another key component of improving the timeliness of health care service delivery is the availability of performance 5 information. By publishing this and other performance data, AHCCCS expects the timeliness of services to members to continue improving. 5 2 Government Performance Project. Longterm Care: The Ticking Bomb. Governing. February 2004. Available at http://governing.com/gpp/2004/long.htm AHCCCS will require corrective action plans from Contractors that have not met Minimum Performance Standards for this indicator in the most recent measurement period. Contractors that fail to show improvement may be subject to sanctions. 3 Cubanski J, Kline J. In Pursuit of Long-term Care: Ensuring Access, Coverage, Quality. The Commonwealth Fund. Issue Brief, April 2002. Available at http://www.cmwf.org/programs/elders/cubansk i_pursuit_ib_536.pdf AHCCCS will work with Contractors, especially those with the lowest rates, to assist them in reaching goals for this Performance Indicator. 4 Brown R, Chen A. Disease Management Options: Issues for State Medicaid Programs to Consider. Mathematica Policy Research Inc.; April 2004. Trends in Health Care Financing Issue Brief, No. 3. References 1 General Accounting Office. Long-term Care: Federal Oversight of Growing Medicaid Home and Community-based Waivers Should be Strengthened. U.S. General Accounting Office, Report to Congressional Requesters. GAO-03576, June 2003. Available at http://www.gao.gov/docdblite/summary.php?re cflag=&accno=A07309&rptno=GAO-03-576 5 McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003; 348:26352645. Available at http://content.nejm.org/cgi/content/full/348/26/ 2635 6 Table 1 AHCCCS ALTCS PERFORMANCE INDICATOR EXCLUSIONS FROM INITIATION OF SERVICES WITHIN 30 DAYS OF ENROLLMENT, ALL CONTRACTORS Measurement Periods: October 1, 2001, through September 30, 2002, and October 1, 2002, through September 30, 2003 n Percent Relative Percent Change 127 55.9% -20.0% 186 69.9% 15 6.6% 8 3.0% 5 2.2% 10 3.8% 65 28.6% 53 19.9% 15 6.6% 9 3.4% TOTAL 227 100.0% TOTAL 266 100.0% Reason for Exclusion Member in Assisted Living Facility Member in Hospice Facility Member Hospitalized Contractor Unable to Contact Member Member Refused All Services 119.7% -41.4% 43.7% 95.3% Shaded rows show results of the first measurement period (October 1, 2001, through September 30, 2002). 7 Table 2 AHCCCS ALTCS PERFORMANCE INDICATOR INITIATION OF HOME AND COMMUNITY BASED SERVICES WITHIN 30 DAYS OF ENROLLMENT BY CONTRACTOR Measurement Periods: October 1, 2001, through September 30, 2002, and October 1, 2002, through September 30, 2003 Service Within Relative Percent 30 Days Change Contractor n Cochise Health Systems * 43 97.7% Cochise Health Systems * 49 98.0% Evercare Select 67 68.7% Evercare Select * 80 81.3% Maricopa LTC 57 68.4% Maricopa LTC * 96 85.4% Mercy Care LTC * 122 81.1% Mercy Care LTC 119 69.7% Pima Health System LTC * 91 97.8% Pima Health System LTC * 90 93.3% Pinal/Gila County LTC * 50 86.0% Pinal/Gila County LTC * 47 83.0% Yavapai County LTC * Yavapai County LTC * 29 89.7% 40 85.0% TOTAL 459 83.7% TOTAL 521 83.5% Statistical Significance -0.3% p=.1.000 -15.5% p=.077 -19.9% p=.012 16.4% p=.040 4.8% p=.169 3.6% p=.681 5.5% p=.724 0.2% p=.944 * Denotes that the Contractor met or exceeded the AHCCCS Minimum Performance Standard. Shaded rows show results of the first measurement period (October 1, 2001, through September 30, 2002). Cells highlighted in yellow indicate statistically signficiant changes from the first to second measurement periods. 8 Appendix A Arizona Health Care Cost Containment System (AHCCCS) Arizona Long Term Care System (ALTCS) Performance Indicator Methodology Project Title: Initiation of Home and Community Based Services Background: In-home services should be provided to ALTCS members in home and community-based settings as quickly as possible after enrollment. These services include, but are not limited to: adult day care, adult foster care, attendant care, behavioral health services, emergency alert services, home-delivered meals, home health aide services, home health nursing, home maintenance services, homemaker assistance, hospice home care services, personal care, and respite services. The AHCCCS Medical Policy Manual (AMPM) requires that service be provided to new enrollees within the first 30 days of enrollment. However, it is preferred that services be started within two weeks of enrollment. Purpose: To evaluate ALTCS Contractor compliance with AHCCCS medical policy in initiating home and community-based services to newly enrolled elderly and physically disabled (E/PD) members. Measurement Periods: October 1, 2001, through September 30, 2002 October 1, 2002, through September 30, 2003 Study Questions: 1. What is the number and percentage (overall, by urban and rural counties, and by individual Contractor) of sample members to whom home and community-based services were provided within 30 days of enrollment? 2. For those members who did not receive services within 30 days of enrollment, what were the reasons for delay in service provision? Population: Sample Frame: All E/PD members newly enrolled in the HCBS program The sample frame consisted of ALTCS E/PD members who: were enrolled for 30 days or more with an ALTCS Contractor during one of the measurement periods, and o were newly placed in the HCBS program. o Sample Frame Exclusions: • This indicator does not include members who are enrolled in the Ventilator Dependent program within the first 30 days of enrollment. AHCCCS requires services for these members to be implemented within 14 days of enrollment. • Members with Prior Period Coverage (PPC) were excluded from the sample frame. PPC is a retroactive period for which Contractors are not responsible for providing case management. i Sample Selection: A statistical software package was used to select a random representative sample by Contractor from the sample frame. The sample size was determined using a confidence level of 95 percent and a 5-percent confidence interval, plus 10 percent oversampling. Sample Strata: Once the random sample was obtained, it was further stratified by urban and rural counties. Data Sources: AHCCCS recipient enrollment data was used to identify members who met the sample frame criteria. AHCCCS encounter data, Contractor claims and member medical or case management records were be used to identify services received by members in the sample frame. Data Collection: • Data was first collected from AHCCCS encounter data. If services within 30 days of enrollment were not found in AHCCCS encounter data, Contractors were asked to provide service delivery information on sample members from one of the sources identified above. • Each Contractor was provided with an electronic file of its sample members for whom services within 30 days of enrollment were not found in the AHCCCS encounter system. AHCCCS requested that Contractors use medical records, including case management notes, to identify whether selected services were provided to those members within the first 30 days of enrollment or provide a reason why services were not initiated for each member. Contractors were required to return their collected data to AHCCCS in a predetermined electronic format. Confidentiality Plan: The Data Analysis and Research (DA&R) Unit in the Division of Health Care Management maintains the following security and confidentiality protocols: • To prevent unauthorized access, the sample member file is maintained on a secure, password-protected computer, by the CRD project lead. • Only DA&R employees who enter or analyze data have access to study data. • Sample files given to Contractors are tracked to ensure that all records are returned. • All employees and Contractors are required to sign a confidentiality agreement. • Member names are never identified or used in reporting. • Upon completion, all study information is removed from the computer and placed on a compact disk, and stored in a secure location. Data Validation: • The sample frame was validated to ensure that members met criteria for inclusion. • Data files received back from Contractors were reviewed to ensure that: o all members included in the sample were listed in the returned data file, o provided services met numerator criteria for this performance indicator, o all requested information was provided, and o incomplete records, according to project guidelines, were identified to Contractors with a request to review and support their corrections. ii To be included in the numerator for study question No. 1, data provided by Contractors must have been accompanied by documentation that included the exact date(s) of service. Indicators: 1. The number and percentage (overall, by urban and rural counties, and by individual Contractor) of members who received at least one of the selected home and community-based services within 30 days of enrollment during the measurement period. 2. The number and percentage of members who did not receive at least one of the selected home and community-based services within 30 days of enrollment during the measurement period, by reason category. Indicator Goals: AHCCCS has established a Minimum Performance Standard that Contractors achieve a rate of at least 74 percent for this indicator. AHCCCS also has established a benchmark, or long-range goal, that Contractors achieve a rate of at least 87 percent for this measure. Denominators: 1. The number of members who met the sample frame criteria, except those who: • refused services • were hospitalized during the first 30 days after enrollment • were receiving hospice services during the first 30 days after enrollment • were residing in an assisted living facility and thus receiving services • could not be contacted after several attempts by the Contractor 2. The number of members who met the sample frame criteria and did not receive a service within 30 days of enrollment, including those who were excluded from denominator No. 1 1. The number of sample members in denominator No. 1 who received at least one of the selected services within 30 days of enrollment in ALTCS 2. The number of sample members in denominator No. 2 who did not receive at least one of the selected home and community-based services within 30 days of enrollment during the measurement period, by reason category: • refused services • were hospitalized • were receiving hospice services • were residing in an assisted living facility • the Contractor was unable to contact the member after repeated attempts • no/other reason was given • The numerator was divided into the corresponding denominator for each indicator (i.e., study question) to determine the indicator rate. • Data for services received within 30 days was analyzed as a statewide aggregate, and by urban and rural counties, to determine overall and urbanand rural- county rates. Numerators: Analysis Plan: iii • The following assumptions were used to determine whether the indicator criteria was met: o Members included in the sample sent to Contractors for which data was not received back from the Contractor were counted as having no service within 30 days. o Any service documented by the Contractor that did not include the exact date it was first delivered was counted as being provided outside the 30day timeframe. Comparative Analysis: • • Overall rates for urban and rural counties were compared. Individual Contractor rates were compared to each other and to the AHCCCS Minimum Performance Standard and Goal. Deviations from HEDIS®: This indicator is based on an AHCCCS contractual requirement and is not based on any nationally recognized methodology, such as the Health Plan Employer Data and Information Set (HEDIS). Deviations from Previous AHCCCS Methodology: • The methodology has been changed from utilizing chart review only to a hybrid methodology. After the sample population has been identified, encounter data will be used to identify those members who received services within 30 days of enrollment. Only sample members who do not have a service encountered within 30 days of enrollment will be sent to the Contractor for medical record review. • In the previous study, members that were in a temporary (Z) placement for more than 30 days were excluded. Since Contractors are responsible for providing service to members upon enrollment, the methodology has been changed to include members in a temporary (Z) placement setting. • When calculating rates for initiation of services within 30 days of enrollment (study question #1), members were excluded for the following reasons: o member/authorized representative refused all services o member was hospitalized o member was in a hospice facility o member was in an assisted living facility o member could not be contacted after several attempts by the Contractor In the previous study, members were not excluded for these reasons when calculating rates of initiation of services. • For the current study, dates associated with the reasons for not providing service(s) and a copy of the medical record, case management notes or claim documenting that services were provided or refused, must have been supplied by the Contractor. This documentation was not required in the previous study. • The following services were measured in previous studies, but were not included in numerator No. 1 for the current study: o transportation o energy assistance o emergency alert o home repair/modification iv durable medical equipment activities of daily living (ADL) training o physical, speech, language or hearing therapies (Refer to attached list, Services Selected for HCBS Performance Indicator) o o Quality Control: • Some habilitation services were included in the current study. These services were not included in the previous study. • Previously, AHCCCS reported the median number of days to initiation of services, as well as rates for type of service provided. AHCCCS has not established contractual performance standards for median number of days and/or rates for initiation of specific types of services, and these rates were not reported. To ensure interrater reliability, AHCCCS: provided each Contractor with the methodology for this indicator. provided each Contractor with a data specification sheet, file layout, and data dictionary for this indicator. • provided Contractors with detailed instructions during meetings. • provided ongoing technical assistance to Contractors. • • v Services Selected for HCBS Performance Indicator Adult Day Health Z3000 Adult Day Health Attendant Care Z3725 Family Attendant Care Z3080 Non-Family Attendant Care Home-Delivered Meals Z3010 Home-Delivered Meals Home Health Aide Z3020 Home Health Aide Home Health Nursing Z3039 Certified HHA - RN/LPN Continuous Care Z3030 Certified HHA - RN/LPN Intermittent Z3038 Non-Certified HHA - LPN Continuous Care Z3037 Non-Certified HHA - LPN Intermittent Z3032 Non-Certified HHA - RN Continuous Care Z3031 Non-Certified HHA - RN Intermittent Z3036 Independent - LPN Continuous Care Z3035 Independent - LPN Intermittent Z3034 Independent - RN Continuous Care Personal Care Z3050 Personal Care Respite Z3060 Short term in home respite care Z3070 Continuous in home respite care Z3061 Group Respite Care Homemaker Z3040 Homemaker Hospice Services 651 Routine Home Care 652 Continuous Home Care Other W2404 Home Respiratory Therapy NonMedicare Certified W2405 Home Respiratory Therapy Medicare Certified Home Agency W2406 Home Respiratory Therapy, Respiratory Therapist Habilitation Z3132 Day Treatment and Training Z3133 Habilitation Group Services (DES) Z3134 Habilitation Group Services (DES, Unit = 1 Hour) Z3033 Independent - RN Intermittent vi